Guidance for health and care professionals

Everyone within a health and care organisation is responsible for managing records appropriately. It is therefore important that you understand how records should be managed - how records are created, maintained and disposed of appropriately.

The Records Management Code of Practice provides a framework for consistent and effective records management based on established standards. It covers organisations working within, or under contract to, the NHS in England. The code also applies to adult social care and public health functions commissioned or delivered by local authorities.

It includes topics such as legal, professional, organisational and individual responsibilities when managing records. It also provides guidance on the storage, retention and deletion of records. Different types of records should be kept for different amounts of time and the Records Management Code includes a retention schedule which sets out how long each type of record should be kept.  

The code is mainly written for those who are designated as responsible for records management within your organisation. This may be a records manager in a trust, a practice manager in a GP surgery or the person who has responsibility for records management in their role at a local authority. However even if this is not a core part of your role, as someone who works in a health and care organisation you should ensure the following: 

You undertake appropriate training and understand your personal responsibilities. You should not handle any patient or service user records until your training has been completed. The training may be provided by your organisation, for example a hospital trust or care home provider, or may be provided by your department, such as a radiology department.

You read and apply your organisation’s policy on managing records.

You understand your professional obligations and adhere to the record keeping standards defined by your registrant body, for example by the General Medical Council, the Nursing and Midwifery Council or Social Work England.

You understand the Caldicott Principles and how to apply them.

You know who is responsible for records management in your organisation in case of any question or query. In smaller organisations this may be a care home manager or practice manager. In larger organisations the member of staff should usually report to the board.