Recommendations for retention of records of COVID-19 vaccination administered under a Patient Specific Direction (PSD)

Jo Jenkins, Specialist Pharmacist (Patient Group Directions) SPS Medicines Use and Safety Division Published

The record retention requirements for COVID-19 vaccinations administered under a Patient Specific Direction reflect the national record keeping standards.

Usual process for retention of records of medicines administered under PSDs

Primary Care

In a GP practice where a PSD is written to authorise the administration of a parenteral POM to a patient by another healthcare professional is:

  1. Prescriber assesses individual.
  2. Prescriber decides administration of a POM is required.
  3. Prescriber completes a direction (authorisation) to administer in the individual’s clinical record or issues a prescription (see below*) – these are both examples of a PSD.
  4. Administration is undertaken by another healthcare professional in line with the PSD.
  5. Administration is recorded in the individual’s clinical record.
  6. The individual’s clinical record is maintained for 8 years for an adult and up to the 26th birthday if given to a child under the age of 18.

*Where the medicine is not purchased by the GP practice and a prescription is used to obtain a named patient supply from a pharmacy, the GP issues a prescription. The prescription is the legal mechanism for the supply of a POM to an individual. There is a legal requirement for this prescription to be retained for 2 years.

Acute Trusts

The above process is replicated in acute trusts where the drug chart forms part of the clinical record and forms the PSD. The patient’s clinical record is maintained for 8 years for an adult and up to the 26th birthday if given to a child under the age of 18. Outpatient prescriptions and TTO are retained for 2 years.

Recommendation for retention of records of COVID-19 vaccination administered under PSDs

Where a PSD is used for the administration of a COVID-19 vaccine the following process is recommended:

  1. Prescriber assesses individual.
  2. Prescriber decides administration of COVID-19 vaccination is appropriate.
  3. Prescriber completes direction to administer in the individual’s clinical record or completes a paper proforma PSD. These are both examples of a PSD.
  4. Administration is undertaken by another healthcare professional in line with the PSD.
  5. Administration is currently recorded via the national IT system. In PCNs there will be a transition to recording on the GP clinical system when functionality is supported.
  6. If a paper PSD is completed, this needs to be included in the individual’s electronic clinical record as this is the legal authorisation for administration. For further advice on scanning documents into clinical records see Records Management Code of Practice for Health and Social Care 2016
    The individual’s clinical record is maintained for 8 years for an adult and up to the 26th birthday if given to a child under the age of 18.