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 such time as the policy review is complete and the new version published, or if national policy or legislative changes are made

1. FUNCTION

The purpose of the policy is to ensure that all NHS Fife Health Records are safeguarded at every stage of the Records Lifecycle Process.

All records created follow a 5-stage lifecycle:

• Create
• Use (modify)
• Maintain (protect)
• Dispose (destroy)
• Archive (preserve)

This policy will focus on the maintain, dispose and archive element of the process.

This document also forms part of NHS Fife’s Health Records Management Plan, element 3 policy, as required by the Public Records (Scotland) Act 2011.

2.  LOCATION

This policy applies to all employees handling Health Records throughout NHS Fife. 

3.  RESPONSIBILITY

All NHS Fife employees who handle or access patient Health Records are responsible for ensuring records are stored, retained and destroyed in accordance with the recommendations of the Scottish Government Records Management Health and Social Care Code of Practice (Scotland) 2024 and NHS Fife’s Health Records Policy.

Each clinical department should have a comprehensive Health Records Management programme with includes cost-effective management of non-current as well as active record, which takes account of their department’s risk management strategy. 

4.  OPERATIONAL SYSTEM

4.1. How long should Health Records be retained (Maintain/Protect)

All records created have an identified retention schedule which varies depending on the record type (see appendix 1). The retention schedules set out in the Scottish Government Records Management Health and Social Care Code of Practice (Scotland) 2024 takes account of legal requirements and sets out the minimum, retention periods for clinical records.

Where an item is not covered in the retention schedule, advice should be sought from the Divisional Health Records Manager. For notes deemed to hold public interest or historic value, to protect the organisations integrity, the Data Protection Officer or SIRO should be contacted in the first instance.

GDPR Principle (e): Storage Limitation – failure to comply with retention periods may result in the risk of non-compliance with legislative requirements GDPR. The Storage Limitation principle states that organisations must not retain personal data for longer than is required. Data should be periodically reviewed and destroyed when out with retention periods.

Public Records (Scotland) Act 2011: Records Management Plan (RMP) – failure to comply with retention may result in non-compliance with legislative and local policy requirements of the NHS Fife RMP, element 5 Retention and element 6 Destruction. Destruction of information should be carried out in accordance with NHS Fife retention schedule.

When a Health Record is retained longer than the normal retention period for example, for Public Inquiries, Medico Legal or ongoing investigations, the reason for the extended retention, and the date the record is destroyed or transferred should be recorded so that any enquiries can be answered promptly and efficiently. 

4.2. Disposal of Health Records Out with Retention

There are three key options for the management of records that have met their retention requirement:

• Scanning – scanning onto an electronic platform, the original copy will be replaced by an electronically held version.
• Archival – a reversible act where notes can be re-accessed by the Health Board, for example, by passing on to another organisation (archivist)
• Destruction – an irreversible act whereby the record is destroyed in its entirety

4.2.1. Scanning

It may be identified that the information retained within the Health Record is of ongoing medical relevance – for example for clinical trial purposes, or an ongoing Inquiry. In these instances, the board may make the decision to scan paperwork to an electronic platform for ongoing retention and destroy the paper copies. The paper copy will be destroyed following locally agreed quality checking procedures being followed and confirmation that the scanned copy is legible.

4.2.2. Archival – Permanent Preservation

No surviving Health Records, older registers or ward journals dated 1948 or earlier should be destroyed as these may be valuable for historical medical and social research. These should be clearly marked to that effect. When identified, they should be transferred to a designated place of archive. 

Non-active records deemed to have archival value should be transferred as early as practicable and no more than 30 years after their creation. The area releasing the records are responsible for advising the archivists is any information released relates to living patients as data protection and confidentiality rights must be considered. (Data Protection Act 2018 Schedule 2 Part 6, paragraph 28). 

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.

All retained records should be boxed and clearly labelled showing the type of material stored, the date of storage and, if appropriate, the destruction date. 

4.3. Retention & Destruction Schedules

Health Records are generated by all medical specialities following an encounter with a patient. The nature for the speciality can have an impact on the retention period for the record. Records for multiple specialities under one directorate (for example Acute Directorate or Health & Social Care Partnership) may be held together in one area. To this end, the timescale for the speciality with the longest retention period should be followed in the event of any crossover of care between specialities which may impact on each other. 

The Scottish Records Management Code of Practice for Health and Social Care V4.0 outlines the Scottish Government recommended retention periods for all record types. 

5.  RISK MANAGEMENT

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

This policy is an integral part of NHS Fife’s system for managing risk as described in the NHS Fife Risk Management Strategy. Failure to comply with this policy could lead to non-compliance of the Public Records (Scotland) Act 2011, NHS Fife Records Management Plan, UK General Data Protection Regulation (UK GDPR) and Freedom of Information (Scotland) 2002.

Any risk will be administered through the DATIX system and any required follow up will incorporate the identification of hazardous working practices. 

6.  RELATED DOCUMENTS

Appendix 1: Scottish Government Records Management Health and Social Care Code of Practice (Scotland) 2024

https://www.gov.scot/publications/records-management-code-practice-health-social-care/

7.  REFERENCES

• Public Records (Scotland) Act 2011.
  • Records Management Code of Practice for Health and Social Care, 2024
  • Freedom of Information (Scotland) Act 2002.
  • UK General Data Protection Regulation (UK GDPR).
  • Scottish Executive Health Department circular HDL (2006) 28 (The Management, Retention and Disposal of Administrative Records)
• Access to Health Records Act 1990
• Scottish Government Guidance Note 008; Decommissioning of NHS Premises