How long should we keep written patient records?
Q Space is becoming a real problem for our practice. Until now, we have kept almost everything – appointment books, visit books, practice diaries, message books – going back to the year dot. We now want to embark on a cull of these bulky written records as most patient information is now held on computer. Are there any pitfalls to avoid? How long should we keep patient records?
A You are not alone. Many practices are finding it difficult to store all their paper records and are asking what, if anything, they really need to keep, particularly when their medical records are computer based.
The problem with pruning medical records is that it is impossible to be certain that any single piece of information is redundant and will never be required again. The counsel of perfection, therefore, is to keep all records indefinitely. However, that advice, as demonstrated by your question, is not always practical.
The limitation period for initiation of civil litigation in the case of adults is 3 years from the date of first knowledge of having a cause of action against a potential defendant. In other words, the clock does not start running until the claimant is aware that they may be able to sue.
For children, the limitation period does not begin to run until they reach the age of 18 years, or the date of first knowledge, if that is later. For incompetent adults, the limitation period does not apply because the patient is never aware of having a cause of action.
To make matters more complicated still, the statute of limitation gives the courts the discretion to allow cases to be brought even though the time limit for initiation of legal proceedings has passed. In general, the test to be applied in these circumstances is whether or not the defendant would be prejudiced by the delay.
For practical purposes, the Medical Protection Society recommends that records relating to adults are retained for at least 10 years and those relating to children, until their 25th birthday.
All other documents containing information that may be relevant to clinical negligence claims or other investigations should be kept for at least 10 years.
Electronic scanning and storage on a CD may be an alternative where that equipment is available; however, it is a laborious process – as anyone who has had to photocopy voluminous patient records for solicitors can testify.
Must we record everything we provide to patients?
Q On a recent course, our practice manager was told that we need to keep records of all the drugs and other items that we provide directly to patients. Is this true, and if so what records do we need to keep and for how long?
A It sounds as if your practice manager has been told about the Consumer Protection Act 1987. The Act provides individuals who have been harmed by faulty products with a means of obtaining compensation without having to prove negligence.
The action is against the manufacturer or the individual who imported the product into the European Union. To be able to trace the individual ultimately responsible, consumers, in this case patients, are entitled to ask the supplier where they obtained the allegedly faulty product. If the supplier cannot give this information, he or she must assume responsibility.
The Act applies to medical practice as the term 'products' is defined as all medicines for oral, topical or parenteral administration, all appliances, prostheses, catheters, drains, instruments, surgical gloves, suture materials or any other items with which patients may come into contact during treatment.
The answer is to keep a record of each item supplied to a patient. The supplier (in this case the practice) should record the date, name of the patient, the product, where appropriate the strength and quantity dispensed, the batch number or, if this is not available, the expiry date, as well as the source of supply. Provided this information can be passed on to the patient, the practice should be absolved of all responsibility.
Product liability claims can be brought up to 11 years after the product was provided, so the records should be retained for that length of time.
Fortunately, product liability claims involving GPs have so far been few and far between; however, all GPs should ensure that they are able to supply this information if required to do so.