Everyone in a health and care organisation is responsible for managing records appropriately.  It is important, therefore, that all general practice staff understand their responsibilities for creating, maintaining, and disposing of records appropriately.

The Records Management Code of Practice

The Records Management Code of Practice provides a framework for consistent and effective records management, based on established standards.

The Code provides detailed advice including on:

• What a record is – in primary care this includes patient records. It also includes administrative and business records such as finance, personnel, estates and practice websites.  Records can be held in a variety of formats including paper, digital, emails, X-rays or photographs.  
• Legal and ethical requirements – all health and care professionals must manage records in accordance with the law. This includes keeping accurate records and only keeping records for as long as necessary.  Staff who are registered to a professional body, such as the General Medical Council (GMC) will also need to follow their guidance. The Caldicott principles also need to be complied with.
• How to keep and store records – this includes the management of both digital and paper records.
• How long to keep records – recommended minimum retention periods for different types of records are set out in the Code. There is also a searchable table where you can look for the minimum retention period for different types of records. You can, for example, search ‘GP’ to find the retention period for GP records (which is continual for a living patient, for example), or ‘building’ to find out how long to keep records relating to building works.
• Action required when the minimum retention period is reached – some records can be destroyed, whereas other records will need to be permanently preserved.

National guidance has been produced in summary form for health and care professionals and this summarises the actions all health and care professionals should take.  

Designated record leads

Your organisation should have a designated member of staff of appropriate seniority who leads on records management (this is likely to be the practice manager). The practice should have approved records management policies and procedures.

Inquiries

It is important to be aware of a number of ongoing inquiries. Examples from the time of writing (January 2023) include the Independent Inquiry into Historic Child Sex Abuse, the Infected Blood Public Inquiry and the COVID-19 inquiry.  This means that records must not be destroyed until guidance is issued by the relevant Inquiry and its terms of reference published.

Related GPG content

• Information governance and data protection
• Purpose of the GP electronic health record
• High quality patient records

Other helpful information

• Academy of Medical Royal Colleges Guidance, Standards for the clinical structure and content of patient records
• British Medical Association Guidance, Retention of health records
• General Medical Council, guidance on Managing and protecting personal information
• Health and Care Professions Council, Standards and record keeping