Clinical Records Policy


ELHT/C013 Version 5.4


Version 5.3


Director of Finance, Information & Planning (SIRO)


Directorate Manager Centralised Outpatients & Administration Service


All Trust Personnel


The Clinical Records Policy sets out the standard required for clinical record keeping, and details the specific requirements relating to health records management within the organisation to ensure the delivery of an effective high quality clinical records service. This policy also sets out the current legislation relating to health records.

To be read in conjunction with:
  • C134 Subject Access Request Policy

  • Information Governance Alliance - Records Management Code of Practice for Health and Social Care 2020
  • Health & Safety Care Act – Duty to Share 2015
  • Academy of Medical Royal Colleges - A Clinician’s Guide to Record Standards
  • Care Quality Commission the right information in the right place at the right time (2009)
  • An organisation with a memory (2000)
  • Confidentiality: NHS codes of practice (2003)
  • Information Security Management: NHS codes of practice (2007)
  • Caldicott Principles
  • National Data Guardian Principles
  • Nursing and midwifery council (2009) Record Keeping – guidance for nursing and midwives
  • Department of Health (2010) Essence of care benchmarking for record keeping
  • Royal College of Physicians (2008) a clinician guide to record standards part 1 & 2
  • Royal College of Physicians (2009) generic medical record keeping standards
  • Waste management policy C071
  • Information Governance Alliance, Record Management Code of Practice for Health & Social Care 2020
  • Photography & Video Records: Policy & Procedure to maintain Confidentiality & Consent, Copyright & Storage ELHT/C88
  • Confidentiality of Personal Information ELHT/C077
  • Health Records Casenote Archiving Procedure
  • RDISOP003 Health Records & Research

  • SOP4 Maternity Records – maternity service guide

Clinical Records Modernisation and Oversight Group

July 2021

Approval Committee

Clinical Records Modernisation and Oversight Group

July 2021

Document approved date

August 2021


Next review date

April 2024



V5 - Policy updated to reflect inclusion of community


records following transfer of community services.


V5.1 – Policy updated to reflect titles/meetings changes


V5.2 – Policy updated to reflect the introduction of the


Information Governance Alliance, Record Management Code of


Practice for Health and Social Care 2016 following the


    withdrawal of the DOH Records Management Code of Practice


Parts 1 & 1.


Title changes


   Inclusion of the HRSG Terms of Reference

V5.3 – Policy updated to reflect the following changes:

-        guidance in relation to the destruction of patient records in light of the Independent Enquiry into Child Sexual Abuse (IICSA)

-        TOR

-        Clinical Audit Schedule

Introduction of General Data Protection Act (GDPR) in relation to Subject Access Requests

V5.4 – Policy updated to reflect the following

-        Removal of ‘TOR’ and ‘Audit Schedule’

-        Renaming of the HRSG to Clinical Records Modernisation and Oversight Group

-        Title changes

-        Revision to supporting references

-        Amendments to section 3 ‘Legal Obligations that apply to records’

-        Amendment to section 14’ Records Security and storage – inclusion of off-site record storage’

-        Inclusion of section 12 ‘National Data Opt Out’

-        Inclusion of section 13 ‘Guidance in relation to the Gender Recognitions Act 2004 – records management’

-        Inclusion of section 16 ‘Records access and auditing’

-        Revision to Appendix one –‘Updated  records management code of practice 2020’


Health Records Retention Schedule – Please refer to the Records Management Code of Practice 2020 pages 51 to 71 as per the link below.


Records Management Code of Practice - NHSX


See Section 14.3. Regarding the temporary suspension of the destruction of health records

Principles to be used in Determining Policy Regarding the Retention and Storage of Essential Maternity Records


British Paediatric Association


Royal College of Midwives


Royal College of Obstetricians and Gynaecologists


United Kingdom Central Council for Nursing, Midwifery and Health Visiting


Joint Position on the Retention of Maternity Records

1.          All essential maternity records should be retained. ’Essential’ maternity records mean those records relating to the care of a mother and baby during pregnancy, labour and the puerperium.


2.          Records that should be retained are those which will, or may, be necessary for further professional use. ’Professional use’ means necessary to the care to be given to the woman during her reproductive life, and/or her baby, or necessary for any investigation that may ensue under the Congenital Disabilities (Civil Liabilities) Act 1976, or any other litigation related to the care of the woman and/or her baby.


3.          Local level decision making with administrators on behalf of the health authority must include proper professional representation when agreeing policy about essential maternity records.


’Proper professional’ in this context should mean a senior medical practitioner(s) concerned in the direct clinical provision of maternity and neonatal services and a senior practising midwife.


4.          Local policy should clearly specify particular records to be retained AND include detail regarding transfer of records, and needs for the final collation of the records for storage. For example, the necessity for inclusion of community midwifery records.


5.          Policy should also determine details of the mechanisms for return and collation for storage, of those records which are held by mothers themselves, during pregnancy and the puerperium.


6.          List of maternity records retained should include the following:


6.1            Documents recording booking data and pre-pregnancy records where appropriate.

6.2 Documentation recording subsequent antenatal visits and examinations.

6.3 Antenatal in-patient records.

6.4        Clinical test results including ultrasonic scans, alpha-feto protein and chorionic villus sampling.

6.5 Blood test reports.

6.6        All intrapartum records to include, initial assessment, partograph and associated records including cardiotocograph.

6.7             Drug prescription and administration records.

6.8       Postnatal records including documents relating to the care of mother and baby, in both the hospital and community setting.


Aspect of compliance being measured or monitored.

Individual responsible for the monitoring

Tool and method of monitoring

Frequency of monitoring

Responsible Group or Committee for monitoring

Outpatient Casenote Availability and Trends

Deputy Health Records Manager

Information is extracted from PAS via business intelligence tool


Clinical Records Modernisation and Oversight Group (CRMOG)

Datix Records related incidents ‘Problems with Patient Records’

Health Records Manager

Datix Reporting tool – Action Plan


Clinical Records Modernisation and Oversight Group (CRMOG)

Recent Care Audit /Basic record keeping standards

Clinical Audit with Medical Staff

Review of case notes


Clinical Records Modernisation and Oversight Group (CRMOG)

Case Note Storage

Health Records Manager

Audit tool / SOP

(previously Annual) to move to Monthly

Clinical Records Modernisation and Oversight Group (CRMOG)

Rationale for Clinical decision making,


 To be agreed

 To be agreed


Correct consultant (new 2021)

Ward managers/ Consultants

On ward EPTS/ Case notes


 Individual ward action plan

NAPF documentation audit (new 2021)

NAPF team

Trust wide documentation audit

One off

Individual ward action plan

IG audit

IG team

Area visit and observations


Individual ward action plan