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Patient Records

Volume 400: debated on Monday 24 February 2003

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To ask the Secretary of State for Health what procedures are in place for correcting false records relating to patients in the NHS. [98120]

Patient records should reflect the observations, judgements and factual information collected by the contributing health professional. Incorrect factual information should be corrected by those responsible for maintaining the record and the Data Protection Act 1998 provides a legal basis for enforcing such corrections when appropriate. An opinion or judgement recorded by a health professional, whether accurate or not, should not be subsequently amended however as it is essential for understanding the clinical decisions that were made and to audit the quality of care.

To ask the Secretary of State for Health what procedures are in place for preventing a health trust (a) destroying records within its possession and (b) failing to disclose information. [98121]

Each National Health Service trust and health authority is legally responsible for managing records and complying with legislation and guidance on disclosing information.In the NHS, guidance and governance arrangements have been designed to assure compliance with law and good practice, while minimising the overheads of managing and auditing detailed procedures. Independent authorities, such as the Audit Commission, Health Service Commissioner and Information Commissioner, oversee the governance arrangements and may impose sanctions where there is a significant failure to comply.Trusts keep records to support patient care and other legal requirements, but it is also necessary to destroy records when they are of no further value. Destruction should be controlled by formal retention and disposal arrangements based on the NHS Retention and Disposal Schedule issued by the Department of Health.Trusts are legally obliged to give patients access to their own personal information, and are expected to be open about their organisation, policies and processes. But there are also circumstances when it is right to withhold information. Such circumstances are set out clearly in published guidance on data protection and openness.

To ask the Secretary of State for Health in whom rests final authority to (a) retain and (b) destroy patient records and associated documentation. [98122]

Final authority for retention or destruction of National Health Service records rests with the individual NHS trust, primary care trust or heath authority concerned.NHS patient and administrative records are public records. The Public Records Act 1958 requires everyone handling public records to manage them responsibly from the time they are created to their eventual destruction or selection for permanent preservation.Destruction of records should only be carried out according to formal retention and disposal arrangements, based on the NHS Retention and Disposal Schedule issued by the Department of Health, but varied by agreement with senior clinical and administrative staff to suit local conditions.The Department of Health last issued guidance on record keeping, with a revised NHS Retention and Disposal Schedule, in 1999. The guidance and disposal schedule are availableon the Department of Health web site at http://www.doh.gov.uk/nhsexec/manrec.htm

To ask the Secretary of State for Health whether it is permissible for medical records to be released on an unsolicited basis by one health trust to another. [98128]

Health records are held in confidence, subject to common law obligations of confidence and the requirements of the Data Protection Act 1998.It would be permissible for a health trust to release medical records to another trust on an unsolicited basis where—there is a legal requirement to do so;there is a public interest in such a disclosure e.g. where child protection issues have arisen;the patient has requested or otherwise consented to the release;the record has been effectively anonymised.