Paper & Electronic Records Retention

Reference: 23-24445

Date response sent: 12/02/2024

Details of enquiry

Policy Documents

1. Please provide a copy of all policy documents, reports, impact assessments, internal guidance, training documents or such other written material relating to the use of keeping and maintaining patient records in any form.

Questions

2. Does the Trust use paper health records as well as electronic health records for patients?
3. Does the Trust have a specific policy governing the use of patient record formats?
4. In what circumstances would a patient have a paper record as well as or instead of an electronic record?
   1. Does the Trust have any circumstances, exceptional or otherwise, in which it would maintain only paper files for medical records (i.e. no electronic health record, or no medical data stored on the electronic health record) for current patients? If so, what are those circumstances?
   2. If so, are any patient records currently held in this way?
5. How many patients have paper records? How many of these patients do not have any/any significant electronic record?
6. What are the answers to question 5 as a percentage of all of the Trust’s patients for whom records are held?
7. How does the Trust deal with physical delivery of hard copy patient notes and records between departments?
8. How does the Trust monitor, audit or restrict access to paper records?
9. How does the Trust store its paper records, both current patient records and historic patient records?

Response sent

Please provide a copy of all policy documents, reports, impact assessments, internal guidance, training documents or such other written material relating to the use of keeping and maintaining patient records in any form.

1. Does the Trust use paper health records as well as electronic health records for patients?

The Trust has been routinely using electronic patient records (EPR) for at least 8 years

2. Does the Trust have a specific policy governing the use of patient record formats?

The format and structure of records is defined by Carenotes, the EPR system in use by the Trust.

3. In what circumstances would a patient have a paper record as well as or instead of an electronic record?

See response to Q4a below

4. Does the Trust have any circumstances, exceptional or otherwise, in which it would maintain only paper files for medical records (i.e. no electronic health record, or no medical data stored on the electronic health record) for current patients?
   1. If so, what are those circumstances?

No.  Were the EPR system were to become unavailable for an extended period, for example for a day or more, then business continuity plans would be activated.  In such cases clinicians would employ the dedicated suite of Microsoft Word template forms which mirror the EPR, fill these in, and upload them to our network drive until such time as they could be re-uploaded back into the EPR.

1. If so, are any patient records currently held in this way?

No

5. How many patients have paper records? How many of these patients do not have any/any significant electronic record?

The Trust holds historic paper records in archive where it is legally required  to do so, to but it is neither maintaining nor creating paper records.

6. What are the answers to question 5 as a percentage of all of the Trust’s patients for whom records are held?

Not applicable

7. How does the Trust deal with physical delivery of hard copy patient notes and records between departments?

Not applicable

8. How does the Trust monitor, audit or restrict access to paper records?

The Trust holds archived paper records on site and they would not normally be accessed other than for destruction or in response to an approved SAR request.

9. How does the Trust store its paper records, both current patient records and historic patient records?

All current patient records are electronic only and not in paper form.  Historical patient records would be kept in archive, in line with the Trust’s retention policy.