Patient records pre 2010 (FOI)

​Request

I understand that the recent digitalisation of hospital records only goes back as far as 2010.  (I have sight of a letter confirming this in writing from the hospital).

Sometimes patient records and history are important from well before that that date, for instance major surgery.

A

What has happened to the paper records pre 2010?

B

How can medical staff access them if they require them?

C

Are there plans to further digitalise the backlog pre 2010 and if so by when can this be expected to be done?

I am assuming that as highly sensitive personal data relating to living individuals these older records will remain extant and available on request (for instance, via a subject access request).

Response

A

Paper medical records are managed in accordance with the retention schedules documented in the NHS Code of Practice on Records Management, and as such are likely to contain records of care and treatment for the life of the patient, unless the retention periods have been applied. 

The paper record is then retained for 8 years post the death of an individual [where the date of death is known to Health and Community Services (HCS)].

There was a digitalisation programme that processed some but not all medical records in 2010. Staff can access these digitalised, archived records via Live Link, or via the HCS Information Governance Team who can provide access. 

Records that were not digitalised at this time have been retained, and therefore, remain accessible to those that need access for continuity of care and review of relevant care needs and clinical history. 

B

Medical Staff can access the medical record by ordering it via the HCS electronic Patient Record system, where the patient’s record has been migrated to this new system. 

Where a patient has not engaged with services for a significant length of time, and therefore, their record was not migrated to the new HCS electronic Patient Record system, the record can be accessed by ordering through the Medical Records Library Team. 

C

There are plans to digitalise medical records and benefit from the efficiencies that this will create for all medical and clerical staff in HCS. 

An update on the Electronic Document Management System and Records Transformation Project programmes’ progress is due to be published imminently. ​