Retaining records

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.

Our recommendations

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.

Further information

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. A prescription or order to supply for (or for practical purposes to administer) to a patient has to be signed by an authorised person/prescriber. The pharmacist screening that prescription/order has to be assured that the prescription/order in front of them is legally valid. All organisations will then require assurance that there is an accurate and complete record kept of what was supplied or administered, on whose authority, by whom, to whom and when. This guidance suggests ways in which this might be achieved.

Good practice points

Consideration should be given to the following points to ensure adherence to good practice.

Confidentiality

Confidentiality should be ensured at every stage of the documentation cycle, including its destruction.

Paper vs Digital

Reliance on hardcopy records is progressively diminishing as they are superseded by digital records, and the balance between paper and electronic records varies by organisation.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 are aligned to NHS England’s Records Management Code of Practice (RMCoP). Replacement of paper systems and records by digital equivalents doesn’t change the fundamental requirements but usually allows them to be met by different means. Those means should be defined to reflect local circumstances, agreed in a senior multidisciplinary forum and be documented in local medicine policies.

Unique record?

These recommendations assume that the pharmacy record is unique and that it includes information which is not held elsewhere. If this is not the case you should use your professional judgment to decide whether or not the recommendation is appropriate for your organisation. Reference to your organisation’s Information Governance Policy may also be help to inform your decision.

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.

Retention periods

The retention periods shown are minimum requirements and a longer period may be required according to local policy.

Specific patient groups

There are requirements covering all types of healthcare records for the treatment of certain groups of patients, such as maternity care, Children and Young People, mental healthcare and cancer care.

Where there are specific requirements for pharmacy-related records for these groups, they can be found in the relevant section within our record keeping resources.

RMCoP provides overarching guidance for these groups of patients.

Scanning records

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

RMCoP contains further information.

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, nas@nationalarchives.gov.uk

Other record keeping resources

• Technical service records in hospital pharmacy
• Additional services records in community pharmacy
• Prescription and dispensing records in community pharmacy
• Controlled Drugs records in pharmacy
• Stock handling, waste and recall records in pharmacy
• Medicines information or advice records in hospital pharmacy
• Prescription and dispensing records in hospital pharmacy
• Clinical governance and patient safety records in pharmacy
• Supply and distribution records in hospital pharmacy
• Miscellaneous records in hospital pharmacy
• Clinical trial records in hospital pharmacy

All record keeping resources

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