How long medical records should be kept is a regular question asked by doctors, and with good reason. It’s a huge responsibility, and one that should be taken with great care, as record holders have a legal and ethical obligation to securely preserve records.
When it comes to the retention of medical records, there’s much to consider. There are also a number of differing circumstances, and some instances where records may need to be kept hold of for longer periods of time than the recommended minimum term.
It is also extremely important to keep in mind the principles of the General Data Protection Regulation (GDPR) when handling medical records. This is because a key principle dictates that personal data should not be retained for any longer than is necessary.
Clearly, however, what is considered ‘necessary’ can be interpreted in many different ways. It is vital, therefore, that if records are kept for longer than is recommended by health departments, the reasons are recorded and made perfectly clear.
In a time-pressured role and environment, effective record keeping is vital for all GPs. It’s important to become adept at maintaining records. It makes the job of a GP far easier when helping patients, and informing the time and care routes taken. In the same way that quality record keeping is key for protecting your judgement, it’s also vital to know how long medical records should be kept.
Minimum recommended GP record retention length
England, Wales and Northern Ireland
GP records should be retained for 10 years after the death of a patient, and electronic patient records (EPRs) must not be deleted or destroyed for the foreseeable future. These recommendations come from the British Medical Association.
The BMA took these minimum retention recommendations from the Information Governance Alliance Records Management Code of Practice for Health and Social Care 2016.
Increased patient access
During November, we discussed the importance of record keeping in healthcare and that patients will soon be able to access their records through an app with the NHS. The fact that patients will shortly have greater access and control over their medical data has brought into sharp focus what is being documented, the quality of that data and how long that data should be stored for.
There is also a whole section on the NHS website dedicated to informing patients about their health records, what is kept in those records and also how to access them.
What information can be included in the record of a patient?
The NHS informs patients that their record can include the following information:
- name, age and address
- health conditions
- medicines and treatments
- historical reaction to medicines and any other allergies
- scans, X-ray and other test results
- information regarding lifestyle, such as whether they smoke or drink
- hospital admission and discharge information
Take a read through our ‘importance of record keeping’ blog post to better understand the important considerations for good record keeping. This includes detailed information on what a patient’s clinical record should include and the other additional important details that should be documented along the way.
If you have any queries about keeping up to date, accurate records and need advice on how long you should keep medical records for, get in touch with MDS today to see how we can help and support you.