Updated guidance on medical records management

The Records Management Code of Practice for Health and Social Care 2016 has recently been replaced by the Records Management Code of Practice 2021.

The code has been published by NHSX and updates and builds on previous versions of the document. It aims to offer consistent guidance on records management across NHS and social care records.

There have been several changes including the intention to make the code easier to read. It also contains more directive guidance on what to do in certain situations without being overly prescriptive.

Retention periods

The retention periods for many key types of medical records remain unchanged, including:

• adult health records not covered by any other section in the schedule are usually retained for eight years
• children's records are retained until 25th birthday, or 26th if the patient was 17 when treatment ended
• GP records for deceased patients are usually retained for 10 years after death
• GP records for patients who have deregistered and the reason is unknown are still to be retained for 100 years however this is under review as outlined in the section below
• mental health records including psychology records are retained for 20 years after cessation of treatment or 10 years after death (previous guidance cited eight years after death)
• obstetrics, maternity, antenatal and postnatal records are to be retained for 25 years after care has ceased but given they are also considered to be part of the child's record, the longer retention period should be considered.

Appendix II details retention periods. Where stipulated, this is intended to be read in conjunction with Appendix III - How to deal with specific types of records. Further guidance is provided on caveats and explanations for these retention periods.

What's new

Other key areas to be aware of include the following.

• New guidance on records management in relation to public inquiries. Relevant records must not be destroyed until guidance is issued by the relevant inquiry.
• A review is planned to be completed by the end of 2023, into the retention time for de-registered GP records to ensure that the costs of retaining them for 100 years are justified. De-registered refers to when a patient is no longer a patient at the practice and not on the GP practice system. Currently, if the reason for de-registration is unknown the electronic record is printed off and sent in paper form to NHS England.
• Previous guidance on complaint case files is contained in Appendix II and remains unchanged. It states that complaints files must always be kept separately from the patient file and retained for 10 years from the closure of the complaint, or any related processes such as litigation.

The code will be updated and is a live document that is subject to amendments. Rather than relying on a downloaded PDF version of the code, you need to check the most recent version via the NHSX website.

Members can contact us for specific advice on records management and retention.

This page was correct at publication on 23/08/2021. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.