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Record keeping

Please see the following list of authoritative resources on record keeping. If you are having any difficulties applying this to your role, please call us.

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General guidance

The Data Protection Act (1998) defines a health record as any record which:

  • consists of information relating to the physical or mental health or condition of an individual, and
  • has been made by or on behalf of a health professional in connection with the care of that individual.

The NMC Code for Nurses and Midwives

RCN publication: Delegating recordkeeping and countersigning records

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Retention and destruction

In principle clinical information should be retained for a minimum period of eight years. GP records should be kept for 10 years after a patient’s death.

In the case of a child record, the records should be retained until the 25th birthday (or 26th birthday if the patient was 17 at the conclusion of the treatment).

Please see:

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Work diaries

The Information Governance Alliance Records Management Code of Practice for Health and Social Care 2016 provides comprehensive detail of best practice in record keeping in relation to information governance, data protection and Caldicott principles. The guidance states that diaries can be considered part of a patient or client's clinical record. Guidance on the retention of health records will apply if diaries are used in this way.

When dealing with children, Health Visitor or District Nurse diaries should be kept for 2 years after the end of year to which the diary relates. Any patient specific information should be transferred to the patient record. Any notes made in the diary as an ’aide memoire’ must also be transferred to the patient record as soon as possible.

It is important to also check the employer's policy on work diaries.

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