The CSP offers a comprehensive document titled ‘Record Keeping Guidance’
PPIPS Guidance on Record Keeping / Retention / Destruction
The CSP document provides the answers to the questions around record keeping, the responsibility that incurs, as well as ‘additional information’ that contributes to a record, how that should be stored, for what length of time and ultimately its destruction.
A brief summary:
Examples of what contributes to ‘record keeping’?
- Written / electronic notes
- reports
- Phone calls
- Text messages
- Emails
- Any other communications e.g. WhatsApp / Skype etc.
How long should I retain records of a child / young person?
In general, records relating to children and young people are kept until the child / young person reaches their 25th birthday or 8 years after the last entry if longer.
These records must be stored securely and in line with GDPR.
Who ‘owns’ the clinical records?
As an individual in independent practiceor practice owner you ‘own’ the notes.
If you are employed or for example, an associate in a private practice, the practice ‘owns’ the notes. If you are an employee, you have to be allowed reasonable access to the notes should that be necessary in view of, for example, a complaint being made against you regarding your treatment of that patient. To avoid potential conflict, it is essential that within any employment contract, that it is specified who owns the notes within that practice.
What happens to my records when I retire?
The notes remain your responsibility.
Once you retire, you must make suitable arrangements for storage of your patient records in order for you or your patients to be able to access them should the need arise in the future and to comply with data laws.
It is recommended that you inform the child, young person and their families of your plans to retire so they are prepared for any transition. Under GDPR regulations, you can only pass a patient's details on to another physiotherapist when you retire if they give explicit consent to be contacted in this way.
What happens when passing on clients to another therapist?
Should you be passing some of your patients on to another physiotherapist you must ask the patient / parent / guardian whether you can share information with the new provider but the records up until this time remain your responsibility.
Ensure you have a written record of how you manage a transfer of care i.e. a letter approaching the patient/ parent / guardian informing them of the proposed transfer of care with an opportunity to object or talk to you about this transfer.
What happens to my records should I die?
It is strongly advised that you nominate someone within your Will to assume responsibility for the retention and destruction of your records otherwise this will automatically pass to the executor/s of your Will.
Destruction of notes
Paper notes need to be shredded, pulped or burnt and disposed of securely. There are companies that provide a shredding service and issue a certificate.
Electronic notes need to be removed from your computer or any additional electronic device. All notes/letters/pictures and reports also need to be removed from any external back-up hard-drives and remote back up services.