Health and social care - records management: code of practice

Section 5 – Record-Specific Guidance

217 In this section you can find additional guidelines for dealing with specific record types. Further information on the record retention periods for health records and NHS corporate records can be found in Annex B.

5.1 Adopted Persons Health Records

218 Records must be recorded under birth names (or alternatively an alias) until an adoption order is granted.

219 This type of record is subject to a high risk of unauthorised disclosure of personal data, especially in relation to third parties, therefore it is recommended that redaction and disclosure instructions are clearly stated along with the record.

220 Any new records derived from the original records of the adopted person must contain sufficient information to allow for a continuity of care.

221 GPs must initiate any changes of the Community Health Index (CHI) number or identity of an adopted person if it is considered appropriate to do so, following the adoption.

5.2 Adult Health Record

222 An acute/secondary care adult health record is the overarching record type for information and records collected and processed by an NHS Board about an individual aged over 16 with regards to their symptoms, assessment, diagnosis, care, and treatment. These records are created by those working within the NHS for all patient interventions across acute and secondary care. The information which would be classed as a ‘adult health record’ may not always be held as a single entity and may be split over formats, systems, and services.

223 This record type does not cover the following specialty records:

• Information held within a GP record;
• Clinical Genetics;
• Dentistry/Orthodontics/Maxillofacial;
• Mental health including; Psychiatry, Psychotherapy, Psychology;
• Learning Disability;
• Midwifery;
• Oncology;
• Ophthalmology/Orthoptics;
• Sexual Health, Genito-Urinary Medicine & Reproductive Health.

224 An adult health record may be in paper or digital format (or both) and may contain any or all of the additional record formats:

• Unstructured digital text, narrative;
• Digital forms;
• Scanned documents;
• Emails;
• Medical illustrations;
• Microfilm/microfiche;
• Photographs;
• Ultrasound scans;
• Video/voice recordings;
• X-ray films/reports.

225 It will contain some or all of the following information:

• personal data and demographics;
• diagnosed health conditions;
• treatments and prescribed medication;
• tests, procedures, operations, and results;
• allergies and past reactions to medicines;
• care plans and referrals to other services;
• lifestyle information, e.g. alcohol and nicotine intake;
• hospital admission and discharge information.

226 The record may hold information from any of the following health specialties:

• AHP Services
• Anaesthetics
• Audiology
• Cardiology
• Clinical Neuropsychology
• Clinical Health Psychology
• Dermatology
• District/Community Nursing
• Ear, Nose & Throat
• Emergency/Unscheduled Care
• Endocrinology
• Gastroenterology
• General Medicine
• General Surgery
• Geriatric Medicine
• Gynaecology
• Haematology
• Homeopathy
• Immunology
• Infectious Diseases
• Intensive Care Medicine
• Major Trauma
• Neurology
• Occupational Medicine
• Orthopaedics
• Palliative Medicine
• Plastic Surgery
• Radiology
• Rehabilitation Medicine
• Renal Medicine
• Respiratory Medicine
• Rheumatology
• Trauma & Orthopaedic
• Tropical Medicine
• Urology
• Vascular Surgery

227 Information pertaining to a person, regardless of format, should be retained in the appropriate clinical system or, where these still exist, the paper record. Emails, referrals, care plans detailing information about a person’s care should be saved to the appropriate record, not within a local storage area with limited access.

228 A single retention period has been introduced for adult health records being held within digital clinical systems (that do not include the specialties listed at paragraph 200), which is to retain until three years after death. This is in order to simplify the application of retention to systems and in recognition of the interdependencies of systems across the health and social care landscape due to the integration of health and social care records.

229 Health Boards should ensure that they have appropriate processes in place to transfer deceased patient health records to their designated place of deposit. It is recommended that Health Boards sample a minimum of two generic records each year for archival preservation. This will provide the country with invaluable information on the treatment of patients throughout history. It is also recommended that Health Boards transfer records of patients who have exceptionally rare diseases/conditions or have received pioneering treatment. To support this, Health Boards should put in place a process for clinicians to identify these records, by marking a paper record or flagging/coding it on a system.

5.3 Allied Health Professional Health Records

230 Allied Health Professionals will create records during the course of their interventions with patients to deliver the following services:

• Arts therapy
• Diagnostic radiography
• Dietetics
• Occupational therapy
• Orthoptics
• Orthotics
• Paramedical Services
• Physiotherapy
• Podiatry
• Prosthetics
• Speech and language therapy
• Therapeutic radiography

231 These records require to be managed alongside the core adult/childrens record or referring specialty record e.g. mental health record. The records should be stored within the core or referring specialty record in order for them to be retained for the appropriate retention period. Where these records are not stored within other records, they should be treated as a core or referring specialty record and stored for the same retention period, with the exception of radiology images.

5.4 Ambulance Service Health Records

232 Ambulance service records must be considered as health records if they contain medical evidence (e.g. clinical interventions), and therefore subject to the same retention periods as their corresponding health records (e.g. adult, children etc.).

233 If Ambulance service records do not contain health data (or data that’s clinical in nature) they must be treated as administrative records (e.g. a patient transport record with no clinical details).

234 The sharing of records between the ambulance service and any organisation part of the wider NHSS (and partners) must be documented in a corresponding Information Sharing Agreement (e.g. National Intra NHS ISA). Suitable work instruction must be written at local level as required e.g. to ensure the ambulance service can access original handover records if needed, to share information with drugs, alcohol, and substance misuse teams etc.

5.5 Asylum Seeker Health Records

235 Records for refugees and asylum seekers must be treated in exactly the same way as other health records. CHI numbers must be allocated. In addition to the digital record, refugees and asylum seekers should be given an eligibility card to help them register if they move to another part of Scotland. Their patient records are maintained on the NHS systems and although they can request copies of their records if they wish, handheld records are not the standard.

236 If a refugee or asylum seeker arrives with a handheld record, this should be used to help populate their NHS Scotland medical record and to create an emergency care summary. The handheld record should be considered similar to an emergency care summary anticipatory care plan, updated after the patient is seen and returned to the patient.

5.6 Childrens Health Record

237 A childrens health record is the overarching record type for information and records collected and processed by an NHS Board about an individual aged under 16 with regards to their symptoms, assessment, diagnosis, care, and treatment. These records are created by those working within the for all patient interventions across acute and secondary care.

238 This record type does not cover the following specialty records

• Information held within a GP record;
• Clinical Genetics;
• Dentistry Orthodontics/Maxillofacial;
• Mental Health/Psychiatry/Psychotherapy/Psychology;
• Learning Disability;
• Midwifery/Obstetrics;
• Oncology;
• Ophthalmology/Orthoptics;
• Sexual Health, Genito-Urinary Medicine & Reproductive Health.

239 A childrens health record may be in paper or digital format (or both) and may contain any or all of the additional record formats:

• Scanned documents;
• Emails;
• Medical illustrations;
• Microfilm/microfiche;
• Photographs;
• Ultrasound scans;
• Video/voice recordings;
• X-ray films/reports.

240 It will contain some or all of the following information:

• personal data and demographics;
• diagnosed health conditions;
• treatments and prescribed medication;
• tests, procedures, operations, and results;
• allergies and past reactions to medicines;
• care plans and referrals to other services;
• lifestyle information, e.g. alcohol and nicotine intake;
• hospital admission and discharge information.

241 The record may hold information from any of the following health specialties:

• AHP Services
• Anaesthetics
• Audiology
• Cardiology
• Dermatology
• District/Community Nursing
• Ear, Nose & Throat
• Emergency/Unscheduled Care
• Endocrinology
• Gastroenterology
• General Medicine
• General Surgery
• Gynaecology
• Haematology
• Immunology
• Infectious Diseases
• Intensive Care Medicine
• Major Trauma
• Neurology
• Neonatal
• Orthopaedics
• Palliative Medicine
• Plastic Surgery
• Radiology
• Rehabilitation Medicine
• Renal Medicine
• Respiratory Medicine
• Rheumatology
• Trauma & Orthopaedic
• Tropical Medicine
• Urology
• Vascular Surgery

242 Where there is ongoing care at the age of 16, the childrens (secondary care) record will transition into an adult record in its entirety. Where there is no ongoing care and the record does not contain information which would require to be retained for longer (see Annex B Records Retention Schedule), then the record (paper or digital) can be destroyed after the person reaches the age of 25.

243 It is recommended retaining childrens health records until the person reaches the age of 25 regardless of whether they are living or deceased. This is to enable the availability of records to assist in the treatment of siblings, particularly where there are genetic conditions and also takes into account the ongoing Scottish Child Abuse Inquiry.

244 Health Boards should ensure that they have appropriate processes in place to transfer deceased patient health records to their designated place of deposit. It is recommended that Health Boards sample two generic records each year for archival preservation. This will provide the country with invaluable information on the treatment of patients throughout history. It is also recommended that Health boards transfer records of patients who have exceptionally rare diseases/conditions or have received pioneering treatment. To support this, Health Boards should put in place a process for clinicians to identify these records, by marking a paper record or flagging/coding it on a system.

5.6.1 Health Visitor Records

245 Health visitors will hold records for the children under their health care. Where these are held separately to the Child Health Team record, NHS Boards should have processes in place to ensure that childrens records are transferred from the Health Visiting Teams to the Child Health Teams when the child reaches school age in order that the records can be maintained together.

5.6.2 School Health Records

246 In line with all patient health records, each child should have their own school health record rather than a single record for the school or per year intake. This ensures that the information about each child is held together meaning that access is restricted to only those caring for that specific child. This also means that it can be transferred to a new school if required. This must only be done once it is confirmed the child is now resident in the new location. The record must be transferred securely. The recipient of the record should contact the sender to confirm receipt of the record (if appropriate).

247 Schools may process some health data on behalf of the NHS, in which case they must follow the records management and data protection processes set by the NHS. Irrespective of the locality of the school, it is the Health Board in which the child resides who is responsible for/the owner of these records.

248 Local Authorities are the controller for health-related information held within school records for their own purposes for example as part of Integrated Support Plans. Where the school is independent, the school itself will be the controller.

249 School Health Records processed on behalf of the NHS, stored on a school premises, must have access restricted to the NHS staff (e.g. school nurse, educational psychologist) delivering care and only be accessed by others where there is a legitimate requirement.

250 These records are subject to the retention periods in this Code of Practice regardless of where they are stored.

5.7 Clinical Psychology Records

251 Records created by Clinical Psychologists, Counselling Psychologists and Clinical Associate’s in Applied Psychology during the course of treatment require to be managed alongside the core adult/childrens record or aligned specialty record.

252 The records should be stored within the core or aligned specialty record in order for them to be retained for the appropriate retention period. Where these records are not stored within other records, they should be treated as a core or aligned specialty record and stored for the following retention periods.

• Records created for patients under the care of mental health services should be held for 20 years after last seen or 3 years after death.
• Records created for patients under the care of acute psychology services, e.g. for clinical assessment prior to proceeding with bariatric surgery, are held within the core adult/childrens record.
• Records for children would be held until the child turned 25, whether living or deceased; or where there is ongoing care these would transition into the adult record.
• Records for neuropsychology care should be retained for 20 years after last seen or 3 years after death, and where neuropsychological assessment has been part of care for long term condition, retention of records should be for the duration of illness as per guidance in section 5.16.

Records for adults would be held for 6 years after last seen or 3 years after death, (whichever date is sooner in both scenarios for paper records and the later for digital records).

253 Some types of test materials used by clinical psychologists require extra security and care in order to protect their integrity. They should be handled in accordance with user agreements and/or user terms and conditions. Organisations should have policy and procedure in place to ensure this is the case.

5.8 Complaints Records

254 Any single complaint must be contained in a single record, regardless of the number of teams involved in the investigation/handling. This will allow a holistic view of the complaint and easier access to the record. The master copy of the complaint including all associated information, e.g. staff statements, should be held within the organisation’s complaint handling team until it exceeds its retention period. Duplicate copies should be held by managers/those involved in investigating the complaint, for a short period of time after the complaint is closed.

255 Complaint information, including opinions about the care that was delivered, should never be recorded in the health, social care or social work records, particularly if the complaint is unfounded.

256 The Scottish Public Service Ombudsman^[30] provides complaints guidance for public authorities. Organisations may develop processes specific to their organisation which should include how complaints records should be managed e.g. the NHS Scotland Complaints Handling Procedure^[31].

5.9 Controlled Drugs Regime

257 Refer to NICE guideline [NG46] (2016) for “Controlled drugs: safe use and management”. They have specific guidelines for record keeping, controlled drugs registers, requisitions, record of destruction and invoices, standard requisition forms, risk assessment records etc.

258 Further information can be found on the Healthcare Improvement Scotland (HIS) website on the safe management and use of controlled drugs.

5.10 Deceased Person’s Health Record

259 Although data protection laws do not apply to data relating to the deceased, the Common Law duty of confidentiality^[32], the right to respect for privacy under Article 8^[33] of the Human Rights Act 1998, and the ethical obligation to respect a patient’s confidentiality, extends beyond death. The duty of confidentiality and right to privacy needs to be balanced with other considerations, such as:

• to assist a Procurator Fiscal or other similar officer in connection with an inquest or fatal accident inquiry;
• as part of national confidential enquiries;
• Medical Certificates of Cause of Death (MCCD);
• where a person has a right of access under the Access to Health Records Act 1990;
• whether the information is already in the public domain;
• the purpose of the disclosure and any benefit or harm that will accrue as a result;
• individuals close to the deceased.

260 The FOISA (section 38(1)d) provides an exemption from the general right of access health records of a deceased person for up to 100 years from the date of the record. Notwithstanding, it may be possible to put in place mechanisms that both safeguard patient confidentiality and enable controlled access to health records of the deceased within this 100-year time limit. In general, confidentiality of records particularly relating to patients, staff, students or minors should be maintained for 100 years from the beginning of the calendar year following the date of the last entry of the record.

261 The Access to Health Records Act 1990 governs access to records of a deceased person. It applies only to records created since 1 November 1991. Access must also be given to information recorded before these dates if this is necessary to make any later part of the records intelligible. The Act allows access to:

• the deceased’s personal representatives (both executors or administrators) to enable them to carry out their duties;
• anyone who has a claim resulting from the death.

262 There is not a general right of access, it is a restricted right, and the following circumstances could limit the applicant’s access:

• if there is evidence that the deceased did not wish for any or part of their information to be disclosed;
• if disclosure of the information would cause serious harm to the physical or mental health of any person;
• if disclosure would identify a third party (i.e. not the patient nor a healthcare professional) who has not consented to that disclosure.

263 In certain circumstances, such as a request for medical records of the deceased, the exemption for confidential information is likely to apply. Organisations must conduct a test of confidentiality prior to disclosure (refer to ICO guidelines “Information provided in confidence” for further details on this test).

264 As with the Data Protection Act 2018, a medical professional or the controller may be required to screen and redact the notes before release as, on occasion, information about the deceased will contain information about other living individuals, including genetic information that may identify surviving relatives (personal data under Data Protection Act 2018).

265 In the case of information about the deceased that is environmental in nature, the Environmental Information (Scotland) Regulations (EIRs) will apply. Where information about the deceased is subject to the EIRs, public authorities should in most cases consider regulation 10(5)(f) as the ‘equivalent’ to section 36 of FOISA.

266 Individual cases will always be decided on the basis of their particular circumstances.

267 Organisations should have processes that address where and how the records of deceased persons are stored. Secure storage is vital to ensure that records are maintained in good order and are available if required. It is essential that organisations put in place processes and procedures to enable the efficient and effective retrieval of such records within the timescales specified by legislation.

268 The retention schedule contains specific provision for the retention of records relating to deceased individuals, in particular:

• cell/tissue transplantation including donated organs from deceased individuals;
• for autopsy reports, specimens etc. where the deceased has been the subject of a Procurator Fiscal autopsy.

5.11 Employee Records

269 Employee records contain information about a person regarding their employment within an organisation. They should hold sufficient information about an employee to track their employment history and for decisions to be made about employment matters.

270 The primary record for each employee should be held by the organisation’s Human Resources department. This record will be created during recruitment processes for new employees and should hold personal data about the employee, i.e. name, address, demographics and also recruitment records, i.e. right to work checks, contract terms and conditions, job description, next of kin details. This record will require to be kept up to date for the duration of the person’s employment, in terms of changes to home address/next of kin, contract amendments i.e. decrease in hours, change of base, recruitment to new post. This record should provide a clear employment history with regards to dates of employment, positions held and location of base.

271 It is common practice within large health care organisations for the line manager to hold the main employee record, containing information relating to the day to day management of the employee. Where this is the case this information should be managed as one record per person for the duration of their career and must be stored securely to ensure there is no inappropriate access. The main employee record will hold various different documents, including but not limited to:

• Job description and contract;
• Access forms for systems and property;
• Training records/certificates for courses attended throughout employment;
• Absence records i.e. return to work forms, maternity/paternity leave forms;
• Copies of ‘Fit to Work’ forms – employees should retain the original;
• Personal development or appraisal paperwork;
• Occupation health information, including any exposure to asbestos, radiation and other chemicals which may cause illness in later life;
• Work-related injury information, including applications for injury allowance scheme;
• Risk assessments e.g. Display Screen Equipment assessment;
• Records of discussions e.g. regarding poor timekeeping.

272 Where records of discussions are created and stored, this should be carried out in line with relevant workforce policies and procedures. Staff members should be aware of the record and have the opportunity to contribute or review accuracy prior to this being added to the record.

273 Some pension information may be held within either the primary or main record; however, it is likely that this information will be held within payroll records. This information should be retained until the persons 75^th birthday or 6 years after the termination of contract, whichever is longer.

274 It is recommended that copies* of information relating to training courses completed by the employee should be retained within their record for their entire employment with the organisation; this is particularly important for statutory, mandatory and professional. *The employee may keep the master copy in order that they can share these with future employers if required.

275 When an employee moves to a different post within the same organisation, the main employee record must be passed to the new line manager in order to ensure the continuity of the record. The content of the record should be reviewed prior to transfer and consideration given as to whether all information within the record can be disclosed to the new manager. The primary employee record held within the Human Resources department should be updated to reflect the change in position, line manager and base.

276 When an employee leaves the organisation the main employee record should be reviewed and transferred to the Human Resources department for inclusion within the primary record. Where this is not possible it is advisable that leavers files are moved to a secure central repository overseen by the Human Resources department and/or those responsible for corporate records management, to be held until the destruction date. Organisations may wish to consider whether a sample or subset of information about ‘leavers’ should be collated annually for transfer to a designated place of deposit for archival preservation.

277 Organisations should develop local guidance outlining how employee records are managed within their organisation, including what they should contain, what format they should be held in, where they should be stored, what the file structure and naming conventions should be and the security measures which must be put in place to prevent in appropriate access.

278 Within Health and Social Care partnerships, there can be instances where a line manager and employee are employed by different organisations. The main employee record maintained by or on behalf of the line manager remains under the ownership of the employee’s employing organisation and should be managed in accordance with that organisation’s policies (and, where the employing body is an NHS Board, in accordance with this Code of Practice). Where there are a range and variety of models currently in use, local arrangements may require to be put in place. These arrangements should be agreed in discussions with both organisations Records Managers/Data Protection Officers. The access to/sharing of employee records should be recognised in local information sharing agreements.

5.11.1 Employee Investigation Records

279 Organisations must ensure that they have adequate written processes in place for the management of employee investigation records outlining what they should contain, what format they should be held in, where they should be stored, what the file structure/naming conventions should be and the security measures which must be put in place to prevent inappropriate access.

280 The master copy of the investigation file should be managed by the Human Resources department. Copies of these files will be provided to key individuals involved in the process. The Human Resources department should clearly be able to identify what documents within the record have been provided to key individuals, when they were provided, whether they were redacted or not and why they were provided. The copies should be held by key individuals in the organisation only until the appeal period has lapsed and the investigation is fully concluded. The master copy will be retained for the retention period.

281 Where there are multiple employees under investigation for the same incident or within the same department, this can be held as one record however each piece of documentation within the record, e.g. statements, reports should only refer to one member of staff under investigation.

5.11.2 Employee Clinical/Educational Supervision Records

282 The supervisor’s record should ideally be held in a centralised, access controlled system. However in the absence of such a system, at present supervisors will also require to store these records within their own ‘personal drive’ or ‘OneDrive’. If the supervisor leaves the organisation, they must ensure that any issues/concerns are raised with the supervisee’s line manager. It may be appropriate in this scenario for the supervision records to be passed to a new supervisor or to the line manager for the retention period as outlined in the retention schedule.

283 The supervisee can store their supervision records within their ‘personal drive’ or ‘OneDrive’ for as long as they feel is required. This forms part of their own personal employment record.

284 Records in relation to line management supervision should be stored by the line manager within the staff record and will be retained in line with the retention period for the staff record.

5.12 Family Health Records

285 Some therapy services may create family records to create a holistic view of the family and their needs. These records are typically assigned to a lead individual with pointers to other members of the family records and vice versa (individuals’ records pointing to the family record held within the lead individual record).

286 The health care record system is, however, based on individual independent records keeping for a number of legal reasons, particular for managing confidentiality and disclosures. Special care is therefore required to avoid unauthorised disclosures. Extensive redaction and special consent may be required.

287 Depending on the purpose of the family record, it is important the most appropriate lead individual is identified, depending on the use to be made of the record, e.g. if it is created to inform intervention to a child rather than a parent, the lead should be the child.

288 The retention period depends on the use of the family record. If it is mainly to inform on a particular patient, e.g. a child (lead individual), the record should be kept following rules for children records, unless other conditions apply (e.g. mental health, child abuse inquiries etc.).

289 If the record is to be used, for example, for interventions to the wider family, the record should be kept in line with the longest retention period applicable.

290 When possible, the record should contain only anonymised data of other members of the family.

5.13 Fertility Treatment Records

291 The Human Fertilisation and Embryology Authority (HFEA) Code of Practice ^[34]refers to specific retention period as per Direction 0012^[35].

292 Licensed centres must retain a record with information about the patient or donor for traceability purposes for a period of at least 30 years from the date on which any gametes or embryos were used in treatment or, if not so used, the date on which any gametes or embryos were removed from storage.

293 In circumstances where the centre is unable to confirm whether or not that patient has given birth to a child as a result of the treatment undertaken at that centre, the record must be kept for 50 years.

294 Additional information related to the safety and quality of gametes and embryos must be kept for a period of at least 10 years after the use of gametes or embryos in treatment.

295 Research projects in this area must keep some minimum details for three years from the date the final report of any research project is submitted to the authority (e.g. number of embryos created, used, or dispose, results, conclusions etc.).

5.14 General Practitioner Records

296 GP records are the primary record of health care from birth to death. Discharge letters and correspondence from other services, e.g. secondary care, must be included in the main record. The GP record transfers with the individual as they change GP throughout their lifetime.

297 The GP record for an individual must be held for the lifetime of the patient, and ten years after death (longer periods may apply in instances of, public inquiries, investigations, fatal accident inquiries etc.).

298 Where the patient does not come back to the practice and the records are not transferred to a new provider, the record must be retained for 100 years. If the patient comes back within 100 years, the retention reverts to 10 years after death or 10 years after they deregister with the practice.

299 When a patient deregisters with a GP practice the following processes should be undertaken dependant on the format of the record:

• The patient’s paper record should be transferred to NHS Scotland Practitioner Services who will arrange for the records to be passed to the new GP practice.
• The patient’s digital record should be copied to the new practice via MedEx. The previous practice should ensure the records is passed digitally in its entirety. The previous practice should then retain their copy of records for deregistered patients for 10 years.

300 When a patient dies, NHS Scotland Practitioner Services will notify the GP Practice that the patient is registered with. The practice should retain the record for 10 years or longer where further investigations are taking place e.g. medical legal claims, investigations, public inquiries etc. Where it is felt that records should be retained for research purposes, the records should be transferred to NHS Scotland Practitioner Services who will retain records for research purposes.

301 The Primary Care Informatics Group have published a number of guidelines concerning the management of GP patient health records; Guidance – Primary Care Informatics (scot.nhs.uk).

302 Also see section 3.0 Responsibilities of processors and sub-contractors.

5.15 Integrated Care Records

303 Integrated or joint care records held by health and social care organisations are subject to local governance arrangements. The partner agencies involved must consider and agree controller/processor roles, scope and purpose of the records, retention schedules, security measures, and work instructions for accessing or updating the records etc. The integrated records agreement must identify the legal basis for the processing across the Partnership, including any data sharing with additional partner agencies.

304 Currently there is no prescribed approach, each public body is responsible for maintaining compliance with all relevant legislation, including the regulatory framework outlined in section 2.3.

305 Potential usage of integrated records includes:

• online portals with role-based access permissions that can be used by several agencies to access the same record/information for different purposes;
• Anticipatory Care Plans or Integrated Care Records;
• fully integrated Customer Relationship Management (CRM) systems.

306 Regardless of the approach taken for integrating health and social care records, an integrated records agreement should be in place and records management rules must be mutually agreed.

307 The NHSS Information Sharing Toolkit should be used wherever NHSS data is concerned.

308 Specific work instructions must be documented to support the operational rules for managing those records by the integrated teams and/or the corresponding records managers.

5.16 Long Term Condition (LTC) Health Records

309 Long Term Conditions records are necessary for continuity of health care. A long term condition is a condition which cannot at present be cured but can be controlled by medication and therapies.

310 Long term conditions include, but are not limited to:

• Angina
• Arthritis
• Asthma
• Atrial Fibrillation
• Back Problems
• Chronic Obstructive Pulmonary Disease
• Coronary heart disease
• Depression
• Diabetes
• Epilepsy
• Heart Failure
• Hepatitis
• Hypertension
• Inflammatory Bowel Disease
• Kidney failure
• Multiple sclerosis

311 The primary record of the illness and course of treatment must be kept of a patient where the illness may reoccur or is a life long illness. The primary/master health record is the GP record. Where the secondary health care record requires to be retained, Health Boards should consider putting processes in place to identify records for long term conditions through coding or flagging/marking digital and paper records to ensure that they are identifiable.

312 This approach is consistent with the direction of NHSS moving towards a more shared service model, where the GP record holds the lifetime view of the patient health. Many patients with long term conditions may have an episode of care in secondary care; the corresponding discharge letters should be kept within the GP record.

5.17 MAPPA Records

313 Multi-Agency Public Protection Arrangements (MAPPA) records are created to support the arrangements in association with managing the risks of serious harm to the public. The Responsible Authorities involved in these arrangements are Police Scotland, Local Authorities, NHS Boards and Scottish Prison Service.

314 As per 5.12 of the National Guidance^[36], the MAPPA Co-ordinator for the relevant Local Authority is the Single Point of Contact (SPoC) for all notifications (and referrals). The MAPPA Co-ordinator should maintain an accurate record of the number of individuals being managed by the Responsible Authorities in their area. Where copies of documents relating to individuals managed under MAPPA are required which are not readily available on Health systems, a request should be made to the local MAPPA Co-ordinator or MAPPA Health Liaison Officer.

315 Within Health Boards, MAPPA records are held separately from the patient’s health records, however alerts may be placed on patient health records in relation to MAPPA arrangements. Copies of records shared by the MAPPA Coordinator with Health Boards, should be stored securely in accordance with their security classification and retained for a minimum amount of time. Health boards (with the exception of the State Hospital), require to retain master copies of records pertaining to the notification to add/remove an alert to a patient record and minutes of internal NHS MAPPA meetings.

316 Where the State Hospital is the Lead Authority for a MAPPA case, generally a restricted patient, they will require to hold the master copy of MAPPA records (notifications, referrals, risk management plan, case review meeting minutes). These records should be held in line with the retention periods within the National Guidance which states: The nominal record will be retained until the 100th anniversary of the individual’s birth.

5.18 Maternity Records

317 Maternity records relating to the health care of a mother and baby during pregnancy, labour and the puerperium must be retained to support the health care to be given to the woman during her reproductive life, and/or her baby, and any future children. Local procedures should be in place which 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 (where paper records still exist); for example, the necessity for inclusion of community midwifery records. The procedure should also determine details of the mechanisms for the return, collation, and storage of those records, which are held by mothers themselves, during pregnancy and the puerperium.

318 Maternity Records should include the following:

• documents recording booking data and pre-pregnancy records where appropriate;
• documentation recording subsequent antenatal visits and examinations;
• antenatal inpatient records;
• clinical test results including ultrasonic scans, alphafeto protein and chorionic villus sampling;
• blood test reports;
• all intrapartum records to include initial assessment, partograph and associated records including cardiotocographs;
• drug prescription and administration records;
• postnatal records including documents relating to the health care of mother and baby, in both the hospital and community settings.

319 Health Boards require to retain obstetric/maternity records until 25 years after the end of the last pregnancy or until the woman reaches the age of 50 due to there being a greater occurrence of women giving birth at more spaced periods of time until later in life. It is also recognised that maternity records can support the health care of siblings especially where genetic conditions were identified.

5.19 Medical Court Reports

320 As part of their professional role, clinicians can be requested to provide a report for Court regarding an individual who is going through the criminal justice process. Clinicians may be asked to do this as part of their NHS employed role or under a private agreement.

321 Court reports should not be stored within the patient’s health record. Equally the reports do not require to be stored as part of the organisation’s corporate records as the organisation has no justifiable purpose for retaining the information. However, it is recognised that clinicians may wish to store a copy of these reports following the submission to court, for their own reference purposes, should they be called to court regarding their report. Given the sensitivity of the reports it is appropriate for these reports to be stored on the clinician’s employer’s digital network in order that they are stored securely.

322 It is advised that the clinician’s own copies of the reports which they have submitted to court should only be retained for the period that the clinician is liable to require to reference the report. Where a clinician changes employer, they should ensure that any court reports which they continue to require access to are moved to a personal repository or their new employer. Any court reports which are no longer required due to completion/closure of the court case should be destroyed confidentially.

323 There is no obligation on NHS Boards to retain copies of court reports. Courts hold the master version of the report for 25 years following which it is passed to the National Records Scotland for permanent preservation.

5.20 Medical Device Records

324 During the course of the delivery of health care, medical devices can be used to support assessment, diagnosis, monitoring and treatment. This could be hardware, software, or appliances ranging from sticking plasters to catheters to pace makers.

325 Where a medical device has been implanted in a patient as part of the care, which is not removed prior to discharge from a hospital or care setting, Health Boards must ensure that records regarding the implantation of the device are retained for the lifetime of the patient plus three years after death even if the device is removed. Examples of implantable medical devices which may not be removed prior to discharge from a hospital or care setting include but are not limited to joint replacements (hip/knee), metal pins, pacemakers, intrauterine device, corneal rings.

326 The legislation covering medical devices is the Medicines and Medical Devices Act 2021^[37] and the UK regulation of medical devices is managed by the Medicines and Healthcare products Regulatory Agency (MHRA).

5.21 Meeting Records

327 Meeting records should generally be recognised as vital corporate records. They can form part of the organisation’s corporate memory, providing evidence of discussions which have taken place at meetings, the outcomes, decisions and actions required in order to support its daily function and operations. They can also provide crucial information which may be used as evidence for investigatory purposes or can be requested under legislation. Meeting records include the agenda, associated papers and minute of the meeting.

328 Meeting records are usually produced for established groups or committees as part of an accountability framework where the purpose is to achieve a stated objective and follow a clear meeting agenda. However, records can also be required for unplanned emergency meetings and investigatory meetings. At meetings where the outcome of the discussion requires to be recorded, minutes of the meeting should be produced in the form of a formal written (typed) minute. It is recognised that audio-visual recording and transcription technology is evolving; however, this technology should not be used in place of the production of a formal written (typed) minutes for meetings where these records are required.

329 Minutes of meetings are a record that the meeting occurred, and outline the topics discussed/actions agreed in meetings. They allow for actions to be tracked, people to be held accountable for actions, those not present to be fully appraised of all discussion and assist in decision making. They can be used as evidence for legal purposes to prove decisions and actions. Minutes of meetings can be of historical importance as they record how the organisation functioned and made decisions in the past. As the organisation evolves, the minutes of meetings from the past can be used as a reference to show how topics were handled and why. Therefore robust processes should be put in place to manage this record set appropriately.

5.22 Mental Health Records

330 Mental Health records are where the person has been cared for under the Mental Health (Care and Treatment) (Scotland) Act 2003 as amended by the Mental Health (Scotland) Act 2015 or where a patient in under the care of mental health services within an NHS Board.

331 Records for any person who in under the care of mental health services or has been detained under the Mental Health (Care and Treatment) (Scotland) Act 2003, and where care is ongoing the record should be kept until the care is complete and 20 years after last contact or 3 years after death if sooner. Social Services records are retained for a longer period. Where there is a joint mental health and social care record, the higher of the two retention periods should be adopted.

332 Records which relate to the detention of a person under the Mental Health (Care & Treatment) (Scotland) Act 2003 require to be completed by the treating NHS Board. Copies of the documentation require to be provided to the Mental Welfare Commission at the time of detention and on revoking the detention to afford the Mental Welfare Commissioner all facilities necessary for them to discharge their functions under the Act, as per Section 17 of the Mental Health (Care and Treatment) (Scotland) Act 2003. These records are not stored within the person’s main mental health record and there is no ongoing obligation for the treating NHS Board to retain this documentation. Records in relation to the detention of a person under the act, once provided to the mental Welfare Commission should be retained to the end of the year which they relate to plus one year, after which they can be destroyed.

333 Mental health entries added into other records must reference the master mental health record and this must not alter the original retention period of the “other” record (where the referenced entry has been done).

334 When the records reach the end of their retention period, they must be reviewed and not automatically destroyed. Such a review should take into account any serious incidents or genetic implications of the patient’s illness. If it is decided to retain the records, they should be subject to regular review.

335 In circumstances when records are released to external bodies for review only, the relevant data should be provided, depending on the purpose for which the record is shared. The justification of the need must be documented, and a note of the sharing added to the record. The justification and details of the type of data shared and recipients should be notified to the Data Protection Officer or the person responsible for the Information Asset Register.

5.23 NHS 24 Records

336 The sharing of records between NHS 24 and any organisation which is part of the wider NHSS (and partners) should be documented in a corresponding Information Sharing Agreement (e.g. National Intra ISA) and suitable work instructions must be written at local level as required.

5.24 Occupational Health Records

337 The main occupational health record must be kept separate from the main employee record and classified as a health record (whereas the employee record is classified as a corporate record). The occupational health record may contain information regarding an employee’s physical and mental health symptoms, diagnosis, ongoing treatment being received, information related to any injuries sustained within the workplace, vaccinations, health surveillance questionnaires, radiation exposure and proposed support, onwards referrals and reasonable adjustments which are recommended.

338 Occupational health information requires to be shared with a Line Manager in order for them to support employees, particularly in terms of making reasonable adjustments under the Equality Act 2010. Consent will be sought from the employee prior to sharing this information. Where information/correspondence is provided to a Line Manager from the Occupational Health department it must be stored within the employee record for the duration of the employee’s career within the organisation.

339 When occupational health records are outsourced, the controller must ensure the processor/contractor can retain the records for the duration of the contract between the controller/processor and that there is a process for the records to be returned back to the organisation upon termination of the controller/processor contract. A process should also be put in place to notify the processor of leavers from the controller organisation in order that this can trigger the six-year retention for the records of those employees who have terminated their employment.

5.25 Oncology Records

340 Oncology records refer to the master oncology record held by oncology teams with regards to surgical or non-surgical treatment, diagnosis, plan construction information, radiation dose, three-dimensional dose distribution information, imaging, systemic anticancer therapy delivered etc.

341 This Code of Practice also applies to the regional oncology centre record (i.e. radiotherapy and chemotherapy).

342 The Royal College of Radiologists state that premature destruction of relevant oncology records may result in preventable death, inappropriate subsequent treatment, or inadequate response to a patient’s lifetime enquiries. For the purposes of health care diagnosis, records of any cancer must be retained in case of future reoccurrence. Where the oncology records are in a main health record, the entire file must be retained.

343 Wherever possible, oncology records should be in a preserved digital format.

344 Oncology records should be reviewed and considered for permanent preservation. The review should be undertaken by the patient’s treating clinician or, in their absence, the clinical head of radiotherapy services.

345 Any oncology record must be reviewed prior to deletion, taking into account any potential long term research value which may require consent or anonymisation of the record.

5.26 Patient/Client-Held Health Records

346 This Code of Practice does not refer to personally held records that the subject of care keeps and controls, but records that are left with the individual for different reasons, e.g. to allow care at home by different health and social care teams, some maternity files.

347 In these cases, the record held by the patient/client must have a clear identification that it is a patient-held record and that they remain the property of the controller and include a return address if they are lost.

348 If these records are the only source of evidence of the treatment or care, they must be transferred to the main health or social care record at the end of the treatment that originated the need for the record to be held by the patient/client.

349 For records permanently retained by the patient/client, the health and/or social care organisation must ensure the data is accurate. The information must be replicated into the health and/or social care files.

5.27 Prison, Youth Offenders & Secure Units (Mental) Health Records

350 Prison Health Records. All healthcare records for prisoners should be kept within the GP record. When a GP is assigned to a prison service, a summary of the GP master record must be transferred to the designated prison GP. Where the sentence is for less than six months, episodic records should be treated as hospital episodes and a summary transferred to the main GP record at the end of the sentence with a discharge letter. The original episodic record is subject to the six years adult rule retention unless other conditions apply (e.g. mental health, appraisal of record etc.). Where the sentence is for more than six months, the record should be treated as a normal GP record and transferred to the main GP record along with a discharge letter (could be the original or a new GP if the prisoner has moved or been relocated). Where a patient is sent to prison the original GP record must not be destroyed until the normal retention periods of GP records have been met.

351 Youth Offending Service Health Records. The health and social care portion of these records are subject to this Code of Practice, e.g. for child health records the retention period generally follows the 25th birthday unless other criteria apply (e.g. mental health, Child Abuse Inquiries, appraisal for permanent retention etc.).

352 Secure Unit Mental Health Records. Some institutions that care for offenders are categorised as hospitals because the offender is considered a patient and has been detained under the Mental Health (Care and Treatment) (Scotland) Act 2003. Such health records are classed as mental health records and must be retained for longer periods of time and normally in excess of 30 years for purposes of the continuity of care or another lawful basis for continued retention.

5.28 Public Health Scotland Records

353 Public Health Scotland is the National Statistics provider for health and social care in Scotland. As part of its remit to support the improvement of the health and wellbeing of the population of Scotland and address the public health challenges, it engages in processing activities which include:

• Collecting/receiving defined data;
• Analysing data and producing health intelligence which inform the actions necessary to address public health challenges in Scotland;
• Supporting research and curating safe data for controlled and authorised access via the national safe haven;
• Evaluating long term impact of national and local policies;
• Publishing long term anonymised trend information.

354 The organisation processes this data in the public interest and as per its legal obligation under the following laws and regulations:

• Statistics and Registration Service Act 2007;
• Official Statistics (Scotland) Amendment Order 2019;
• Code of Practice for Statistics 2022;
• Public Health Scotland Order 2019;
• Public Health etc. (Scotland) Act 2008;
• National Health Service (Scotland) Act 1978;
• International Health Regulations (2005);
• UK Focal Point Communications Protocol on Serious Cross-border Threats to Health.

355 Public Health Scotland will retain personal data for as long as processing is necessary in the public interest to meet its obligations as the national public health agency for Scotland. These retention periods will be detailed and justified in Public Health Scotland’s relevant data protection impact assessments which support the processing and set out its local records management retention policy.

356 Public Health Scotland will impose retention periods on personal data which is no longer necessary for processing. Examples include when a bespoke analytical project runs for a defined period and comes to an end, when the outputs are published as part of its transparency obligations in compliance with the code of practice for statistics. The retention periods will be specified in the relevant data protection impact assessments.

5.29 Public Inquiry Records

357 In the event of an Inquiry being convened under the Inquiries Act 2005 (see section 2.3.5), organisations should take action to ensure it is able to capture and retain records as evidence. Records identified as being of potential relevance to the inquiry must not be destroyed or disposed of until there is clear instruction from the inquiry team that they are not required.

358 It is recommended that the following steps are undertaken:

• Issue a communication to raise awareness of the Inquiry and requirement to identify and protect information and records which may be of relevance;
• Amend retention schedules/records management policies to highlight the requirement to protect relevant documentation from destruction;
• Undertake a scoping exercise to identify the information and records of relevance, where they are stored and the volume;
• Agree a single point of contact for the collation of evidence;
• Agree how and where evidence will be stored once collected;
• Ensure that an accurate inventory of records submitted is held by the organisation and maintained. In some instances, the Inquiry Team will also expect an inventory to accompany each submission of evidence/statements.

359 Information or records, in the form of statements or evidence, submitted to the Inquiry must be retained as part of the Inquiry record permanently and when appropriate deposited with the designated permanent place of deposit.

360 Records which were retained beyond their retention period due to the inquiry, however, were then deemed not relevant or not used in the proceedings of the inquiry can be destroyed one year after the closure of the inquiry.

5.30 Sexual Health Records

361 These records must be treated as particularly sensitive. Current legislation require that special confidentiality and unauthorised disclosure controls are in place to ensure information about sexually transmitted infections are treated appropriately. Special restrictions for sharing this type of information apply, for these reasons it is common practice these records are managed separately from the main health record.

5.31 Sexual Offence Examination Records

362 The Forensic Medical Services (Victims of Sexual Offences) (Scotland) Act 2021 (FMS Act) places a statutory duty on health boards to provide Forensic Medical Examination (FME) and healthcare services for victims of sexual offences. Each health board has established a Sexual Assault Response Co-ordination Service (SARCS). A person can access a SARCS if they report the incident to the police within the ‘forensic window’ (seven days), or they can self-refer without first having to make a report to the police. Information on the service can be found on the NHS website.

363 The Forensic Medical Services (Self-Referral Evidence Retention Period) (Scotland) Regulations 2022 sets out specific retention periods for the evidence gathered during a FME which can be found detailed within the retention schedule.

364 Section 17 of the FMS Act clarifies that “evidence” does not include information that is gathered for a purpose other than to be used for a police investigation or subsequent proceedings: for example, information gathered for the purpose of determining a person’s healthcare needs following the incident is not considered evidence. Records relating to healthcare information gathered at the same time as the forensic medical examination, for example the healthcare form and associated healthcare records, should be stored, retained and destroyed in line with adult health record retention periods.

365 Section 9 of the FMS Act sets out the situation where the offence is reported to the police. The appointed police officer will contact the SARCS directly to arrange the uplift of evidence, statements and forensic reports and will provide a signed copy of the mandate for forensic documentation to the SARCS facility, which will then be stored with the health record. The time frame for the Health Board to retain a copy of the Sexual Offences Against Adults Forensic Form is five years from the date the forensic form is provided to the police (or when a self-referral converts to a police referral). This will ensure that clinicians are able to prepare fully for giving evidence in court without needing to request a copy of the forensic form from the COPFS. This time frame does not impact the 26-month retention period for self-referral evidence when no police report is made.

366 Section 8 of the FMS Act sets out the rules for the destruction of evidence and associated forensic information. When the record has exceeded its retention period, all documentation in relation to the forensic examination (not the health care assessment), including photographs and colposcopy images, should be securely disposed of within at least five working days of the end of the retention period, to ensure consistency in practice across the country.

367 If a person decides that following the examination they will not, at any time, be reporting to the police, they can request the health board destroy any evidence provided by them at any time before the end of the retention period. A 30-day cooling off period will apply to this request and health boards must therefore ensure that evidence is destroyed only after the expiry of the 30-day period. The exception is if the request is made in the last 30 days of the retention period, in which case any evidence must be destroyed as soon as is reasonably practicable after the expiry of the retention period (unless the person decides to report the matter to the police before the expiry of the retention period).

368 Processes must be put in place by health boards to ensure that all records associated with the evidence are retained/destroyed in line with these retention periods. A Self-Referral National Protocol has been put in place to support these processes.

5.32 Specimens and Samples

369 The retention of human material is not in scope of this Code of Practice. The metadata or records regarding the sample or specimen are, however, covered by this Code of Practice. Relevant professional bodies such as the Human Tissue Authority or the Royal College of Pathologists have issued guidance on how long to keep human material.

370 As human material is not kept for long periods, this does not mean that the information about the specimen or sample should be destroyed at the same time. The information about any process involving human material must be kept for continuity of health care and legal obligations. The correct place to keep information about the patient is within the health record and although pathology reports may be retained by the individual pathology departments, a copy must always be included on the health record.

371 The General Data Protection Regulation defines genetic data as personal data within the special categories; therefore records must be processed according to the special categories’ rules.

5.33 Transgender Persons Health Records

372 The Data Collection and Publication Guidance, Sex, Gender Identity and Trans Status^[38], provides the following definitions of sex and gender:

• Biological sex: as determined by a person’s anatomy, which is produced by a combination of their chromosomal, hormonal, genital and gonadal characteristics, and their interactions.
• Legal sex: typically legal sex is their sex registered at birth. However, for a person with a full Gender Recognition Certificate, their legal sex is their acquired sex.
• Self-defined sex: a person’s innate sense of whether they are female or male
• Gender: a social construction relating to a set of norms, roles and relationships that is founded in social mores, laws, processes and policies based on labels of masculinity and femininity. Gender is time- and culture-specific.
• Gender identity: a personal, internal perception of oneself, and so the gender category someone identifies with may not match their sex registered at birth. What an individual experiences as their innate sense of themselves as a man, a woman, as having no gender identity, or as having a non-binary gender, where people identify as somewhere on a spectrum between man and woman
• Transgender: anyone whose gender identity differs from their sex registered at birth.

373 Transgender patients have rights in having their gender identity recognised and recorded in their health records. However, cognisance needs to be taken that this may have unintended negative consequence to their overall health, where a name and gender identity is recorded which differs from their biological sex at birth, and new health records are not appropriately linked to previous records.^[39]

374 Within a health and social care setting, patients have the right to request to change their Male/Female marker on their patient health record without the requirement of a Gender Recognition Certificate (GRC) or updated birth certificate. Patients can choose to be issued with a new CHI number to reflect their gender identity. Once the patient has been issued with a new CHI number, a new record is created which is linked to the patient’s previous record, known as the ‘historic’ record. Male/Female markers and any demographic information related to the patient’s previous identity should be removed from the historic record. Information related to previous healthcare provided which would indicate that the person has changed gender, for example reference to a breast or genital examination, should remain. Information on the requirements for processing a change of record can be accessed via NHS National Services Scotland - How to change patient details (nss.nhs.scot).

375 The Gender Recognition Act 2004^[40] allows individuals to change their legal sex by obtaining a GRC which allows an updated birth certificate to be issued showing their updated legal sex. A patient who does not obtain a GRC retains the legal sex as identified on their birth certificate. However, whether or not they have a GRC, transgender patients have a range of rights on the basis of their gender reassignment under section 7 of the Equality Act 2010^[41] which provides “A person has the protected characteristic of gender reassignment if the person is proposing to undergo, is undergoing or has undergone a process (or part of a process) for the purpose of reassigning the persons’ sex by changing physiological or other attributes of sex.” The Equality Act 2010 does not require a patient to be under medical supervision to have this “protected” characteristic.

376 Under section 22 of the Gender Recognition Act 2004 (Gender Recognition Act 2004 (legislation.gov.uk)) it is a criminal offence for “a person who has acquired protected information in an official capacity to disclose the information to any other person”. Protected information refers to either a person's application for, or their gender identity prior to obtaining, a Gender Recognition Certificate to change their legal sex. There are various exceptions specified in section 22 and in Orders under the section^[42] which allow for some protected information to be disclosed.

377 When documenting a patient’s gender identity, it is important that their human rights, legal rights and rights to privacy are considered. In some circumstances during the provision of health care, it will be important for clinicians to have access to both biological sex and gender identity to support the appropriate provision of care and treatment, whilst upholding the patient’s rights. Decisions based on, for example test results, can differ between those with chromosome XX and those with chromosome XY due to physiological and biological differences. Therefore a clinical risk could be created if the biological sex is not known and/or accessible via a historic record, as a treatment pathway may be required to be based on the patient’s biological sex instead of their gender identity. This consideration should be discussed with patients who are requesting to amend their health record, most commonly the CHI number.

378 Initiatives are underway across health care to review systems and consider how they can be adapted to collect both biological sex and gender identity. When undertaking this work, groups should be mindful of the information and further guidance which is contained within this section.

379 Further advice can be found on the following links:

• MDDUS - The care of transgender patients by GPs (mddus.com)
• GMC Ethical Hub - Trans healthcare (gmc-uk.org)
• Sex, gender identity, trans status - data collection and publication: guidance (gov.scot)

5.34 Witness Protection Health Records

380 These records are subject to greater security and confidentiality measures. The right to anonymity extends to medical records. A new CHI number is assigned, and a new set of health records must be created.

381 Relevant data necessary for continuity of care must be recreated in the new record. If transferring data from previous records, special redaction measures must be taken to ensure anonymity is guaranteed.

5.35 Records in Specific Formats

5.35.1 Medical Images and Video Recordings

382 During the course of health care, patients will undergo tests and procedures to support the diagnosis and treatment of their symptoms and conditions. At times this may involve procedures which result in the production of images or recordings. Images and recordings will be reviewed by the appropriate clinical staff and in some cases a report will be produced detailing the outcome of the review of the image/recording and the professional opinion of the clinician with regards to the findings, diagnosis, treatment and/or further procedures required.

383 It is acknowledged that the file size of medical images and medical recordings may in some cases be significant and the long term storage of these will have an impact on storage capacity and costs associated with this. Where a summary/outcome report has been created there may not be a requirement for the image/recording to be retained for the lifetime of the patient and a further three years after death (or up to the age of 25 if the patient died before they were 17) as the image/recording may then be able to be viewed as transitory. However, when considering the appropriate retention period for large media files used in the course of health care, advice should be sought from the organisation’s Health Records Manager to ensure decisions are made on a specialty by specialty basis taking into account future care needs, retention periods of the associated specialty record, quality control processes and potential for future investigations.

5.35.2 Emails

384 Email is a format of information and not all emails will constitute a record. Organisations must have an email policy with clear rules for managing, storing, deleting, and sending/disclosing emails. Failure to manage emails indicates a weakness in records management. Organisations should consider the implementation of special training plans and an audit of working practice to identify and address poor practice. Refer to The National Archives guidance on emails for further details on the management of emails as records and the means of ensuring they are captured, managed and stored in the appropriate area so that they are accessible and usable to all relevant parts of the organisation.

385 When emails need to be retained, they must be preserved in their entirety, including any attachments, to protect their integrity. They should be saved to the correct records repository, which will not normally be the email account. Email accounts are not recognised as storage repositories for organisational records.

386 Deliberate deletion of emails (or any other information) with the intention of frustrating a request for information under the Freedom of Information (Scotland) Act 2002 and Data Protection Act 2018 once a request for information has been received (e.g. a Freedom of Information request or a Subject Access Request) may be a criminal office. Emails also need to be managed securely and in line with relevant policy and guidance, for example: UK Government Secure email guidance (gov.uk).

387 Deliberate deletion of emails (or any other information) with the intention of frustrating a request for information under the Freedom of Information (Scotland) Act 2002 or a subject access request may be a criminal offence under FOISA or the Data Protection Act 2018.

388 Where email accounts are portable across organisations, processes must be put in place to ensure data is not transferred to the new organisation unless necessary. It is poor practice to purge email accounts when individuals transfer to other organisations, as some emails may be considered as corporate records, and must be kept where necessary.

389 Emails, as with all correspondence, in relation to patient health and social care, must be kept within their corresponding health and/or social care record.

5.35.3 Websites and Intranet

390 Websites and intranets are digital means to provide vital information and communications to the public and employees, in an organised manner. As published information, it is important that website and intranet content is captured and retained as part of an organisation’s records and therefore they are subject to this Code of Practice. Information published on an organisation’s website may influence the behaviour of an individual, who may respond to the content accordingly. It is important to capture what information was available from the site at a given moment in time and variations (updates) to content published on the website/intranet. Websites/intranets must be subject to change management and the history of the record must be traceable (what was published at a point in time). Methods to recreate websites/intranets must be considered (e.g. crawls to be stored) including for traceability of dynamic content.

391 The websites of Scottish public authorities who transfer their records to the National Records of Scotland (NRS) for permanent preservation, will have their websites regularly ‘snapshot’ by the NRS Web Continuity Service and added to the NRS Web Archive as part of their deposit arrangements.

392 The National Library of Scotland (NLS) is entitled under the terms of the Legal Deposit Libraries Act 2003 to request a copy of all printed items published in the United Kingdom. From 6th April 2013, the Legal Deposit Libraries (Non-Print) Regulations 2013 extended this to include the right to harvest UK electronic publications, including websites. The NLS has a Memorandum of Understanding with the Scottish Government to preserve and make accessible, Scottish Government websites. This includes websites with a UK domain, e.g. .scot, or .uk. This does not cover intranets, email, databases, and anything stored in the cloud or social media. This content is archived by the UK Web Archive. Some UK Web Archive website content can be accessed via the UK Web Archive (webarchive.org.uk) website but secure access to most legal deposit copies is available only from the NLS reading rooms in Edinburgh and Glasgow.

393 In exceptional circumstances, public authorities may request the UK Web Archive to undertake web crawls and capture on their behalf. An organisation’s designated place of deposit may also be able to crawl and capture website content.

394 As Intranets are utilised for communicating information internally to organisations and sit behind private IP addresses, the UK Web Archive and the NRS Web Continuity Service do not include intranets as part of their web crawl service. It is therefore the responsibility of the organisation to ensure that intranet content, or even the entire intranet, is subject to the records management process.

395 Organisations should note that a web archive does not negate the need to also transfer the original records selected for permanent preservation to a designated place of deposit, regardless of whether they are also published on websites.

5.35.4 Social Media

396 When organisations implement social media channels as a means of communication, they should put an acceptable use policy in place which also outlines the requirement for a risk assessment, process for the registration of the information asset, designation of an IAO and the requirement to follow data protection policies.

397 In a health and social care setting, social media is used for circulating information regarding the activities of the organisation or providing generic advice to the population, rather than as a way of communicating with patients about their direct care. Information posted on social media (such as health campaigns, advice on where to seek support) will usually be captured elsewhere in an organisation’s corporate records function, and where this is the case, there is no value in retaining the information held in the social media platform, as it will be a duplication. However in instances where it is not captured, appropriate measure should be put in place to retain the information in line with the organisation’s retention schedule. If a social media platform is utilised by the organisation and it is possible to export posts, the schedule and analytics when required this should be done on a regular basis. Where this is not possible organisations should document the activity through transcription or periodic storage e.g. snapshot. This is especially pertinent to social media posts which could be required as part of an investigation/public inquiry or designated as of historical interest for example the coverage of a major incident such as the Covid-19 pandemic.