Pharmacy records retention covering statement
Background
Storage of large volumes of paper records received and produced by pharmacies and pharmacy departments can be difficult, costly and space consuming. Retrieval of records can also be difficult if they have not been archived adequately. Increasingly information is created and stored electronically, however, similar issues apply with regard to only storing relevant information and retaining itin such a way that it is easy to access when required.
As a result of a lack of guidance on the retention of hospital pharmacy records, the Eastern Region Senior Pharmacy Managers Network published recommendations based on legislation, where it existed, and broad consensus of best practice in the Hospital Pharmacist journal in 2003 and 2008. (1, 2) The recommendations were reviewed and updatedby the East of England Senior Pharmacy Managers Network and published in the Pharmaceutical Journal in 2010 and 2012.(3, 4) In the 2012 version information pertinent to community pharmacies was included and in 2015 recommendations for pharmacies in secure environments were added. (4, 5)
NHS Code of Practice
The Department of Health first publishedan NHS Code of Practice for records management in March 2006. (6)This was reviewed and an updated version published in January 2009, which referenced the pharmacy records retention recommendations to the 2008 Hospital Pharmacistarticle. (2, 7)
In July 2016 the Information Governance Alliance (IGA) published the Records Management Code of Practice for Health and Social Care for the Department of Health. (8) The Code is based on current legal requirements and professional best practice. The Code addresses storage of paper records and also information held digitally. As an increasing number of records and data are held only as electronic records the Code notes that it is technically difficult and time consuming to maintain digital records over time. Destruction of digital information is also challenging, it is more than just deleting a record which may then be reversed and the information recovered. It is important to keep accurate records of destruction decisions. .
Records of operational activity should contain relevant descriptive and technical information and be complete, accurate and unambiguous. Records created should be readily understandable and auditable by current and future employees. The records should ensure protection of the legal and other rights of the employing organisation, including patients, staff and any other people affected. It should be possible to authenticate the records so that the evidence derived from them is shown to be credible and authoritative. (6, 7)All records are subject to disclosure under the Freedom of Information Act 2000. If no format is specified for a particular record, it is important to make sure that it is clear and unambiguous to guard against any risk of misinterpretation. The case for retaining non-mandatory records should be carefully considered.
Review and Update
To ensure that information on retention and storage of pharmacy records and documents is current, the East of England Senior Pharmacy Managers Network have again reviewed and updated their recommendations. The recommendations in the table are the result of the review process. They are intended as a guide based on the best available evidence at the time of publication.Acute Trust pharmacy managers must discuss these recommendations with their clinical governance managers and the Trust solicitors before putting them into practice. Community pharmacy managers should discuss application of the relevant recommendations with the superintendent of their employing organisation, local commissioning senior pharmacist or clinical governance lead. Pharmacists (and technicians) working in secure environments should discuss these recommendations with healthcare provider and employing organisation.This is particularly important where current practice varies from that recommended in this document. TheEast of England Senior Pharmacy Managers Networkaccepts no liability for the recommendations made.
Feedback
The recommendations may alter as guidance and legislation changes or as experience in application of the recommendations dictates. This guidance has the support of the NHS East of England pharmacy leads. Any feedback will be welcomed in order that revisions and refinements can be made at a later date. Comments should be made to Katie Smith, Director, East Anglia Medicines Information Service (email – ).
References
- Recommendations for the retention of Pharmacy records. Hospital Pharmacist 2003; 10 (5): 222-4.
- Recommendations for the retention of Pharmacy records. Hospital Pharmacist 2008; 15 (7/8): 254-6.
- Recommendations for the retention of Pharmacy records. Pharmaceutical Journal 2010; 285: 119-122.
- How to keep proper pharmacy records — a downloadable good practice guide. Pharmaceutical Journal 2013; 290: 621.
- Recommendations for the retention of Pharmacy Records. March 2015
- Records Management: NHS Code of Practice, Parts 1 & 2. Department of Health, March 2006.
- Records Management: NHS Code of Practice, Parts 1 & 2. Department of Health, January 2009.
- Records Management Code of Practice for Health and Social Care 2016. Information Governance Alliance, July 2016.
November 2016
Katie Smith
Director - East Anglia Medicines Information Service
IpswichHospital, Heath Road, Ipswich, Suffolk, IP4 5PD
01473 704431