Accurate and timely records are part of robust clinical governance. Everyone within a health and care organisation is responsible for managing records appropriately. It is therefore important that you understand how records should be managed. This includes how records are created, maintained, accessed and disposed of.
This resource is intended as a comprehensive but concise first point of reference for pharmacy professionals and as an aid to local decision making. In some circumstances more than one piece of legislation is relevant to a specific record or situation and requirements of each may appear to conflict with one another.
Where no relevant legal requirement or national guidance has been identified, a ‘best practice’ recommendation may be given. Organisations may also have their own local policy, recommendations or requirements.
Chief Pharmacists responsibilities
In all circumstances, the final decision about the most appropriate course of action to take over retention and storage of pharmacy and medicines-related records rests with the Chief Pharmacist of the organisations concerned.
If you are in any doubt as to the interpretation of any of the requirements or recommendations in this resource, review the associated reference for further information.
Applying the guidance
This guidance is applicable to pharmacy departments and services commissioned by or contracted by NHS England. Requirements that apply to England also apply to The Devolved Administrations in most cases, but there are also some differences, such as for Patient Group Directions.
Reliance on hardcopy records is progressively diminishing as they are superseded by digital records, and the balance between paper and electronic records varies by organisation. The principles in this guidance apply to both paper and electronic records, and is aligned to the Department of Health and Social Care’s Records Management, NHS Code of Practice 2021.
Good practice points
Consideration should be given to the following points to ensure adherence to good practice.
Confidentiality should be ensured at every stage of the documentation cycle, including its destruction.
Freedom of Information legislation
Procedures should be in place to cover disposal of any records to ensure compliance with Freedom of Information Legislation.
Managing electronic records
Electronic records must backed up appropriately; supported by audit trails that record details of all additions, changes and deletions.
In practice, retention of these records is indefinite because they are electronic.
The retention periods shown are minimum requirements and a longer period may be required according to local policy.
There are specific requirements covering certain groups of patients e.g. Maternity, Children and Young People, Mental Health, and Oncology
Paper records may be scanned provided the correct procedures are followed in committing the record to digital image.
Such records must be:
- correctly labelled and archived
- records kept of the destruction of the original paper record
- the scanned copy legally admissible in a court of law if necessary
Further information can be found at Records Management Code of Practice for Health and Social Care 2021.
Storing paper records
Paper records may be stored in a designated secondary facility, covered by appropriate procedures for archiving and subsequent disposal.
NHS organisations considering storing paper records for permanent preservation are advised to contact the National Advisory Services at the National Archives for guidance on this process and up to date information concerning relevant Places of Deposit. The list of contact addresses for Places of Deposit for public records appointed to hold NHS records can be found by contacting the National Advisory Services, The National Archives, Kew, Richmond, Surrey TW9 4DU, email@example.com