Scottish Government Records Management: NHS Code of Practice (Scotland) Version 2.0

Records Management Code of Practice


ANNEX E - ADMINISTRATIVE RECORDS RETENTION SCHEDULE

This schedule sets out minimum periods for which the various administrative records created within the NHS or predecessor bodies should be retained (in line with the Principle 5 of The Data Protection Act 1998), either due to their ongoing administrative value or as a result of statutory requirement. Records are listed alphabetically within each record category, e.g. financial, human resources. The retention schedules apply to all the records concerned, irrespective of the format ( e.g. paper, databases, emails, photographs, CDROMs) in which they are created or held.

The review, to be undertaken by local organizations, will determine whether records are to be selected for permanent preservation, destroyed or retained for research or litigation purposes.

Whenever the schedule is used, the guidelines listed below should be followed:

i. The minimum retention periods in this schedule must be adopted. However, local business requirements or risk analysis may require some categories of record to be kept for longer.

ii. Recommended minimum retention periods should be calculated from the end of the calendar or accounting year following the last entry on the document.

iii. The provisions of the Data Protection Act 1998 and the Freedom of Information (Scotland) Act 2002 must be observed. Decisions should also be considered in the light of the need to preserve records that may be in the substantial public interest or in relation to research purposes (Section 33(3) contains some exemptions from the 5th principle of the Data Protection Act 1998.) This applies to records whose use cannot be anticipated fully at the present time, but which may be of value to future generations.

iv. Some classes of document must be permanently preserved and the advice of the local NHS archivist, NAS (National Archives of Scotland) or the Scottish Government eHealth Directorate regarding an appropriate place of deposit should be obtained.

v. The selection of records for permanent archival preservation is partly informed by precedent (the establishment of a continuity of selection) and partly by the historical context of the subject (the informed identification of a selection). It is also possible to retain a sample of certain record series. General rules should be drawn up locally, using the profile of material that has already been selected, and the history of the institution or organisation (including pioneering treatments and examples of excellence) within the context of its service to the local and wider communities.

vi. Files and documents which, having been retained for the minimum retention period, are selected for destruction, should be destroyed appropriately, with particular regard being to whether the information contained in them is of a confidential or sensitive nature.

Administrative Records - General

TYPE/ SUBTYPE OF RECORDS

MINIMUM RETENTION PERIODS

NOTES

Conferences: lectures given by staff at other conferences

permanent

Significant conference papers should be selected for permanent retention

Conferences: organised by Boards - conference proceedings

permanent

Conferences: organised by Boards - routine paperwork

destroy after conference

Conferences: other conferences attended by staff

2 years

Copies of out-letters ("flimsies")

1 year

Databases- records handling system

permanent

Retain to demonstrate implementation of established practice and provide audit trail, see also Indexes

Diaries - office

1 year after completion

Indexes- file and document lists marked for permanent preservation

permanent

Indexes- file and document lists not marked for permanent preservation

Destroy when no longer useful

Retention may be required if they are part of audit trails

Quality Assurance Records

12 years

Receipts for registered and recorded delivery mail

2 years

Records of custody and transfer of keys

2 years

Research and development findings by Board staff (scientific, technological and medical)

Consider findings and reports for permanent preservation

Supporting records should be retained in line with the appropriate clinical, pharmaceutical, laboratory or other research standards, as set out by funding and professional bodies.

Software licenses

Operational lifetime of product

Administrative Records - Financial

TYPE/ SUBTYPE OF RECORDS

MINIMUM RETENTION PERIODS

NOTES
SEE FOOT NOTE

Accounts - final annual master copies

permanent

Accounts - cost

3 years

Accounts - working papers

3 years

Accounts - minor records: (including pass books, paying-in slips, cheque counterfoils, cancelled/discharged cheques, petty cash expenditure, travelling and subsistence accounts, minor vouchers, duplicate receipt books, income records, laundry lists)

3 years after completion of audit

See 'Receipts for cheques bearing printed receipts' below

Accounts - statutory final

permanent

Advice Notes

3 years after formal clearance by statutory auditor

A longer period may be required for investigative purposes

Audit records - original documents

3 years after formal clearance by statutory auditor

A longer period may be required for investigative purposes

Audit reports (including Management letters, VFM reports and system/final accounts memorandum)

3 years after formal clearance by statutory auditor

A longer period may be required for investigative purposes

Bank statements

3 years after completion of audit

Benefactions - endowments, legacies gifts etc.

permanent

Bills and receipts

6 years

Budget monitoring reports

3 years

Budgets

2 years after completion of audit

Capital paid invoices

3 years

See 'Invoices' below

Cash books and sheets

6 years

Cost accounts

See 'Accounts' above

Creditor payments

3 years

Debtors' records - cleared

6 years

Debtors' records - uncleared

6 years

Demand Notes

6 years

Expenses claims

See 'Accounts - minor' above

Financial plans, estimates recovery plans

6 years

Funding data

6 years

General ledgers

6 years

Income and expenditure sheets and journals

6 years

Indemnity Forms

6 years after the indemnity has lapsed

Inquiries involving fraud/other irregularities

10 years

Where action is in prospect or has been commenced, consult with legal representatives and NHS Counter Fraud Services and keep in accordance with advice provided

Invoices payable (creditors)

6 years

Invoices receivable (debtors)

6 years

Ledgers

6 years

See also 'General ledgers' above

Mortgage documents - acquisition, transfer and disposal

permanent

Non-exchequer funds records

See 'Income and expenditure journals' above

PAYE records

6 years

Receipts

6 years

Includes cheques bearing printed receipts

SFR returns

6 years

Superannuation - accounts and registers

10 years

Superannuation - forms

10 years

Tax forms

6 years

VAT records

6 years

In some instances a shorter period may be allowed, but agreement must be obtained from HM Revenue and Customs

Wages/salary records

10 years

For superannuation purposes authorities, may wish to retain such records until the subject reaches pensionable age

The Scottish Government policy on retention of financial records is set out in the Scottish Public Finance Manual, which can be accessed at: http://www.scotland.gov.uk/library5/finance/spfm/spf-00.asp.

Administrative Records - Property, Environment and Health & Safety

TYPE/ SUBTYPE OF RECORDS

MINIMUM RETENTION PERIODS

NOTES

Agreements

See 'Contracts' below

Buildings - papers relating to occupation

Permanent or until property demolished or disposed

Does not include Health & Safety information

Capital charges data

3 years after completion of previous 5 year valuation term

Contaminated Land

permanent

Contracts - non sealed (property) on termination

6 years

Environmental Information

permanent

Equipment

See 'Products - liability' under 'Procurement Records'

Estimates: including supporting calculations and statistics

3 years

Green code

permanent

Health and safety:

Asbestos Register

permanent

Health and safety:

Audit forms, COSHH (Control of Substances Hazardous to Health Regulations) documentation, safety risk data sheets, risk assessments and control measures etc.

10 years

Health and Safety:

Accident and Incident Forms

10 years

See 'Litigation dossiers' under ' NHS Board Records'

Health and Safety: Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 ( RIDDOR) including Accident Register

10 years

Inspection Reports - e.g. boilers, lifts etc.

2 years after operational lifetime of installation / plant

Should be retained indefinitely if there is any measurable risk of a liability

Inventories (non-current) of items having an operational lifetime of less than 5 years

2 years

Land purchase and sale - deeds, leases, maps, surveys, registers etc

permanent

Land purchase and sale -negotiations not completed

6 years

Laundry lists

See 'Accounts - minor' under 'Financial Records'

Manuals - operating

See 'Inspection reports' above

Manuals- policy and procedure

permanent

Maintenance contracts

See 'Property- Cleaning and Maintenance' below

Maintenance request book

2 years after financial year referred to

Maps

consider for permanent preservation

Project files (£250,000 and over)

permanent

Including abandoned or deferred projects

Project files (under £250,000)

6 years after completion / abandonment of project

Project team files (£250,000 and over)

3 years

Project team files (under £250,000)

3 years

Property- acquisition dossiers

permanent

Property - cleaning and maintenance (contracts less than £100,000)

6 years

Property - disposal dossiers

permanent

Property/ Estates- Land, Building and Engineering Construction Procurement:

Key records (including:

final accounts, surveys, site plans, bills of quantities, PFI/ PPP records)

Town and country planning matters and all formal contract documents (including: executed agreements, conditions of contract, specifications,

"as built" record drawings and documents on the appointment and conditions of engagement of private buildings and engineering consultants)

permanent

Inclusive of major projects abandoned or deferred

Property - leases

permanent

Property management system

permanent

Property - minor contracts

6 years

Property performance

permanent

Property - purchases

permanent

Property strategy

permanent

Property - title deeds

permanent

Property- terriers ( NHS premises site information)

permanent

Safety Action Bulletins

Permanent

SEPA Registrations, Licenses and Consents

permanent

Specifications for work tendered

6 years

Tenders (successful)

See 'Contracts' above

Tenders (unsuccessful)

6 years

Waste Consignment Notes- Controlled wastes such as clinical/ healthcare and household/ domestic

2 years

Waste Consignment Notes- Special/ Hazardous/ Radioactive Wastes

3 years

Waste- Duty of Care Inspection Reports

permanent, or for life of external contract

Administrative Records - Human Resource

TYPE/ SUBTYPE OF RECORDS

MINIMUM RETENTION PERIODS

NOTES

Disciplinary: First written warning

6 months

Disciplinary: Final written warning

12 months

Disciplinary: First and final written warning

12 months

Disciplinary: Letter of Dismissal

10 years

Where action is in prospect or has been commenced, consult with legal representatives and keep in accordance with advice provided.

Disciplinary: Records of action taken, including: Details of rules breached, Employee's defence or mitigation, Action taken and reasons for it, Details of appeal and any subsequent developments

6 years after leaving service

See above for retention periods for warnings.

Establishment records - major (including: Personnel files, letters of application and appointment, confirmation of qualifications, contracts, joining forms, references & related correspondence, termination forms)

6 years after leaving service

Establishment records - minor (including: attendance books, annual leave records, duty rosters, clock cards, timesheets)

2 years

Industrial relations (not routine)

permanent

Personal Development: Nurses - training records

30 years after completion of training

Applies only to Nurse Training carried out in hospital based nurse training schools

Personal Development: Study leave applications

2 years

Recruitment: Applications for employment- unsuccessful applicants

1 year after completion of recruitment procedure

Recruitment: CVs for non-executive directors (successful)

5 years following end of term of office

Recruitment: CVs for non-executive directors (unsuccessful applicants)

2 years

Recruitment: Disclosure Scotland information

90 days

90 days after the date on which recruitment or other relevant decisions have been taken; or 90 days after the date on which recruitment or other relevant decisions have been taken.

Recruitment: Job advertisements

1 year

Administrative Records - Procurement and Stores

TYPE/ SUBTYPE OF RECORDS

MINIMUM RETENTION PERIODS

NOTES

Approval files - contracts

permanent

Approved suppliers lists

11 years

Delivery notes

2 years

Indents

2 years after financial year referred to

Medical equipment specifications - major items purchased

permanent

Medical Equipment- operating manuals

operational lifetime of equipment

Procurement documentation

7 years

One copy of each supplier response from short listed to tender and the contract itself.

Products - liability

11 years

Purchase orders

3 years after financial year referred to

Requisitions

2 years after financial year referred to

Stock control reports

2 years

Stores - major (ledgers etc.)

6 years

Stores - minor (requisitions, issue notes, transfer vouchers, goods received books etc.)

2 years

Supplier correspondence

6 years after termination of agreement

Supplies records - minor ( e.g. invitations to tender and inadmissible tenders, routine papers relating to catering and demands for furniture, equipment, stationery and other supplies)

2 years

Administrative Records - NHS Board

TYPE/ SUBTYPE OF RECORDS

MINIMUM RETENTION PERIODS

NOTES

Area health plans

permanent

Contracts - non sealed on termination

6 years

Contracts- GP Practices and others to deliver core NHS services

permanent

Contracts - sealed

permanent

Including associated records

Corporate policies

permanent

Deeds of title

permanent

Health promotion - core papers and visual materials relating to major initiatives

consider permanent preservation

History of Boards or their predecessor organisations

permanent

History of hospitals

permanent

Hospital services files

consider permanent preservation

Legal actions (adult)

7 years after case settled or dropped

Legal actions (child)

until child is 18 or 7 years after case settled or dropped, whichever is later

Litigation dossiers - complaints including accident reports

10 years

Where a legal action has commenced see Legal actions

Meeting papers - master set

permanent

Main committees and sub-committees of NHS Boards and special Health Boards and other meetings of significance for legal, administrative or historical reasons

Minutes - master set

permanent

Main committees and sub-committees of NHS Boards and special Health Boards

NHS circulars - master set

permanent

Nursing homes pre 1 April 2002: registration documents and building plans

permanent

The regulation of care services was taken over by the Care Commission on 1st April 2002.

Nursing homes pre 1 April 2002: inspection reports and general correspondence

5 years

The regulation of care services was taken over by the Care Commission on 1st April 2002.

Option appraisals

6 years after end of agreement

Patient complaints without litigation -adults

7 years

Patient complaints without litigation - children and young adults

until child is 16 or 7 years, whichever is later

Photographs

consider for permanent preservation

Corporate and publicity photographs, not used those for patient care purposes.

Press cuttings

consider for permanent preservation

Register of seals

permanent

Reports - major

permanent

Serious incident files

permanent

Service development reports

6 years

Service level agreements

6 years

Strategic plans

permanent

Subject files

permanent

Files relating directly to the formulation of policy and major controversies must be permanently preserved. Other files should be disposed of when no longer needed.

Trust arrangements legally administered by NHS organisations - documents describing terms of foundation/ establishment and winding-up

permanent

Trusts arrangements legally administered by NHS organisations - other documents

6 years

Administrative Records - Service Planning

TYPE/ SUBTYPE OF RECORDS

MINIMUM RETENTION PERIODS

NOTES

Activity monitoring reports

6 years after end of agreement

Admission, transfer and treatment of patients- policy files

permanent

Databases - demographic and epidemiological based on data supplied by NHS National Service Scotland, Information Services

In accordance with general policies of NHS National Service Scotland, Information Services, and any specific terms and conditions imposed by them in relation to particular data sets

Databases - demographic and epidemiological based on survey data

May be retained indefinitely if data quality and potential for future re-use justifies cost of migration / regeneration to new formats and platforms

Patient activity data

3 years

Summary bed statistics

permanent

Waiting list monitoring reports

6 years

Winter business plans

6 years

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