General Note

NHS Fife acknowledges and agrees with the importance of regular and timely review of policy statements and aims to review policies within the timescales set out.
New policies will be subject to a review date of no more than 1 year from the date of first issue.

Reviewed policies will have a review date set that is relevant to the content (advised by the author) but will be no longer than 3 years.

If a policy is past its review date then the content will remain extant until either such time as the policy review is complete and the new version published, or there are national policy or legislative changes.

1 FUNCTION

To ensure that NHS Fife’s Health Records are retained and destroyed in accordance with the recommendations of the Scottish Government Records Management Health and Social Care Code of Practice (Scotland) 2020 and NHS Fife’s Health Records Policy.

This document also forms part of NHS Fife’s Health Records Management Plan, as required by the Public Records (Scotland) Act 2011.

2 LOCATION

This policy is NHS Fife wide.

3 RESPONSIBILITY

All NHS Fife staff with responsibility for control of Health Records.

4 OPERATIONAL SYSTEM

4.1 How long should health records be retained?

The length of the retention period depends upon the type of record; its importance to the business of NHS Fife; and also upon legal requirements. The destruction of records is an irreversible act, whilst the cost of keeping them can be high and continuing. The retention schedules set out herein take account of legal requirements and sets out the minimum retention periods for clinical records. There is local discretion to keep some material for longer, subject to local needs and affordability. However, where records contain personal information, the requirements of the Data Protection Act 1998 must be met – records must not be kept for longer than necessary. Where an item is not covered in the retention schedule, advice should be sought from the Divisional Health Records Managers or the Caldicott Guardians.

4.2 Disposing of records

There are two principal options - to destroy or to dispose, for example, by passing on to another organisation. As can be seen from the retention schedules set out herein, some records have fixed retention periods, whilst others will need more careful consideration. All staff who handle records should be aware of the vital role that records play in delivering health care. Each department should have a comprehensive records management programme which includes cost-effective management of non-current as well as active records, and which takes account of their department’s risk management strategy.

4.3 What are the options for disposal?

Disposal of paper records does not just mean destruction. It can also mean the transfer of records from (say) paper onto a computer/scanner; or from one user to another. Most NHS records are destroyed as soon as practicable after the expiry of the relevant minimum retention period, but there are other options for disposal. The destruction of records is an irreversible act, so it is vital to consider all the options and get the decision right.

When an important Health Records is retained longer than the normal retention period, the date the health records is destroyed or transferred should be recorded so that any access requests can be answered promptly and efficiently.

4.4 How should records be destroyed?

Most NHS records, even administrative ones, contain sensitive or confidential information. It is therefore vital that confidentiality is safeguarded at every stage and that the method used to destroy such records is fully effective and secures their complete illegibility. Normally this will involve shredding, pulping, or incineration. This can be done on site, or via an approved contractor, but it is the responsibility of NHS Fife to satisfy itself that the methods used throughout the process provide adequate safeguards against accidental loss, or disclosure of their contents. It is recommended that a brief description be kept of everything that has been destroyed, when, and by whom, and where a contractor is used, they should be required to sign confidentiality undertakings and to produce written certification as proof of destruction.

4.4.1

It is essential that the destruction process is documented. The following information should be recorded and preserved so that the organisation is aware of those records that have been destroyed and are therefore no longer available. Disposal schedules would constitute the basis of such a record.

• Description of record
• Reference number if applicable
• Number of records destroyed
• Date of destruction
• Who authorised destruction
• Who carried out the process
• Reason for destruction (Referring to retention & destruction policy.)

4.4.2

Whenever patients records are destroyed the relevant Master Patient Index should be updated with the date of destruction so that this is immediately known should the patient represent to the service or make an enquiry for access to their health record.

4.4.3

If a record is known to be the subject of a request for information or potential
legal action, destruction should be delayed until disclosure has taken place. It is important to note that section 65 of FOISA and Regulation 19 of the Environmental Information (Scotland) Regulations 2004 provide that it is a criminal offence to destroy, etc, records with the intent to prevent disclosure.

4.5 Records which must be permanently preserved

Documents of historical importance must not be destroyed and should be marked clearly to that effect.

No surviving health record dated 1948 or earlier should be destroyed and some categories of post-’48 records must also be preserved. (See NHS Fife’s Retention and Disposal Schedules: Appendix 1). There is an obligation to preserve appropriate records for historical use by a wide range of readers in the future. The most appropriate method of retaining a selection of case notes for permanent preservation is by way of sampling. NHS Fife have access to the services of a professional archivist at Fife Council to look after their non-current health records and make them available both to staff of NHS Fife and members of the public in consultation with the Keeper of the Records of Scotland.

If in doubt about the classification of the record, refer to the NHS Fife Divisional Health Records Managers.

Where records are being retained, they should be boxed and clearly labelled showing the type of material stored, the date of storage and the destruction date, where appropriate.

4.6 Retention & Destruction Schedules

The key areas where records are generated within NHS Fife are identified as:

1. Health Records

• Hospital
• Health & Social Care Partnership

In the following schedules, each area has identified the internal records managed, the period of retention and outlined the local storage and transportation procedure reflecting the core standards and the NHS Fife named representative.

At the conclusion of periods set out in this guidance the records may be destroyed but there is no obligation to do so (please refer to the NHS Fife Retention and Destruction Schedule: Appendix 1).

Destruction of health records should be based on appropriate health professional advice. Where departments are not directly specified, they should refer to the section outlining the type of record and follow the procedure.

Additional Considerations

Effective and efficient management of records must be considered during the following: (As Per Scottish Government Guidance note 008; Decommissioning of NHS Premises)

• Closure of a service
• Relocation of sites
• Demolition/Unexpected loss of Buildings
• Fire & Flood

4.7 Archival advice

All records management procedures with respect to NHS records, especially those that may be candidates for permanent preservation because of their wider medical or historical importance, should be informed by advice from a qualified Archivist.

5. RISK MANAGEMENT

There is a risk to the organisation of breach of legal requirements to retain clinical information for the required time scales if this policy is not adhered to.

6. RELATED DOCUMENTS

Appendix 1 NHS Fife Retention and Disposal Schedule
NHS Fife Health Record Policy GP/R9

7. REFERENCES

Public Records (Scotland) Act 2011
Access to Health Records Act 1990
Data Protection Act 1998
Freedom of Information (Scotland ) Act 2002
Scottish Government Records Management Health and Social
Care Code of Practice (Scotland) 2020
Section 65 of FOISA and Regulation 19
Environmental Information (Scotland) Regulations 2004
Scottish Government Guidance note 008; Decommissioning of NHS Premises