Retention of medical records
The value of retaining records for longer periods is so they can assist in responding to a complaint or claim
Until the Health Information Bill is passed into law, there are no national guidelines for the retention of healthcare records other than those produced by the National Hospitals Office for public hospitals. These, however, are based on common-sense principles that are equally applicable in the private sector (see Further reading for the link to this document).
In the absence of a national policy, MPS recommends the minimum retention periods set out in Box 10.
The value of retaining records for longer periods is so they can assist in responding to a complaint or claim. The recommended minimum retention periods are guidelines only and it may sometimes be necessary to take an individual approach to some records and retain for longer periods.
Box 10: Recommended minimum retention periods
- Healthcare records of an adult – eight years after last treatment or death.
- Children and young people – until the patient’s 25th birthday, or 26th if the young person was 17 at the conclusion of treatment, or eight years after the patient’s death. Guidelines for public hospitals also recommend keeping records for longer periods if the contents have relevance to adult conditions or have genetic implications.
- Maternity records – 25 years after the birth of the last child.
- Records of a mentally disordered patient – 20 years after last treatment or eight years after death.
Disposal of records
You should keep a register of all healthcare records that have been destroyed or otherwise disposed of
Clinical records may be transferred to the National Archives rather than be destroyed, if they are of archival value. If records are to be destroyed, paper records should be shredded or incinerated. CDs, DVDs, hard disks and other forms of electronic storage should be overwritten with random data or physically destroyed. Be wary of selling or donating secondhand computers – “deleted” information can often still be recovered from a computer’s hard drive.
If you use an outside contractor to dispose of patient-identifiable information, it is crucial that you have a confidentiality agreement in place and that the contractor provides you with certification that the files have been destroyed.
You should keep a register of all healthcare records that have been destroyed or otherwise disposed of. The register should include the reference number (if any), the patient’s name, address and date of birth, the start and end dates of the record’s contents, the date of disposal and the name and signature of the person carrying out or arranging for the disposal.
If a patient transfers to another doctor, you should forward a copy of the patient’s records to the new doctor, while retaining the original for your own records. These should be disposed of at the end of the retention period in your records management policy.