Efficient Record Retention: Ensuring Patient Care and Legal Protection

Incision Indemnity
General -
15th January 2024
3 mins read

Efficient Record Retention: Ensuring Patient Care and Legal Protection

We understand the significance of precise and comprehensive patient records. These records aren’t just a professional obligation; they form the bedrock of excellent patient care and provide a crucial shield in medico-legal contexts. Should complaints, claims, or regulatory actions arise, these records become instrumental in defending your position.

Creating patient records is just the beginning; the responsibility persists for years. Safely storing these records for extended periods is imperative, anticipating their potential necessity for future clinical care or legal proceedings. This daily concern resonates deeply with private practice surgeons, doctors, and clinics.

This guidance aims to empower our members and audience, with a clear understanding of their obligations and best practices. While offering insights, it also addresses frequent queries received by Incision’s medico-legal advisors. Remember, more tailored advice is readily accessible to Incision members through our 24/7 medico-legal helpline.

How Long to Retain Records?

For private practitioners, adherence to The Private and Voluntary Health Care (England) Regulations 2001 (Schedule 3) establishes minimum retention periods:

Patients treated under 17: Retain records until their 25th birthday.

Patients treated at 17: Records should be kept until their 26th birthday.

Deceased patients under 18: Maintain records for eight years from the date of death.

Patients treated for mental disorders: Retain records for 20 years or eight years from death or last entry.

All other cases: Retention for eight years from the date of the last entry in patient records.

While these are minimums, considering prolonged retention may be sensible based on practice specifics. Assessing clinical and legal reasons for retaining records for several years becomes crucial.

Clinical Perspective:

Evaluate if certain procedures necessitate detailed medical records beyond eight years. Typically, key details within GP correspondence cover prolonged periods.

Legal Perspective:

Align record retention with the patient’s claim expiration. Most claims end within the statutory eight-year minimum, but exceptions exist for patients “under a disability” or instances of ‘latent’ errors taking years to surface.

Record Retention Complexity:

Storage duration varies per individual practice, influenced by the volume and type of records. Tailoring your storage approach to meet these specific needs becomes crucial.

Document creation and transfer to patient files require meticulous administrative processes to ensure reliable record preservation. Security remains paramount, especially for sensitive health data. Encryption might be necessary for electronic records. Continued accessibility is vital; foresee fail-safes for accessing records, even in the case of incapacity or hardware obsolescence. Securely destroy or delete records post the relevant retention period.

Insurance and Record Protection:

Incision policies encompass protection against inadvertent record loss, data breaches, or related GMC investigations. Contact our medico-legal helpline promptly in case of lost records or data breaches for expert guidance and insurance support.


January 2024