Contents
1 Aim
As a trust we are required to keep records for specified periods of time after involvements with patients, service users, or staff have ended. The period of time for keeping these closed records varies dependent upon the nature of the involvement that the trust had with the individual. The retention period for each type of record is specified in the Records Management Code of Practice 2021 (opens in new window).
This document contains guidance in relation to the processes for preparing and retrieving closed records.
2 Scope
This standard operating procedure applies to all staff working within the trust who are involved in handling patient, service user and staff personal information and any other trust records that are required to be sent off site for storage or retrieved from storage.
3 Links to any other associated documents
This SOP is is over-arched by and should be used in conjunction with the corporate records policy.
4 Procedure or implementation
4.1 File or box pre-preparation
Prior to files being sent to offsite storage staff should:
- ensure all loose filing has been placed in the file
- do not use lever arch files unless they are full as these can be laid flat (approximately 4 or 5 per box)
- do not use plastic folders or punched pockets, use paper-based folders or envelopes, plastic can cause records to sweat and is environmentally unfriendly when recycling destroyed records
- each box should be filled with files that have the same destruction date. This will minimise time taken to prepare files for destruction in the future. The offsite storage facility will carry out destruction on behalf of the trust at the end of the retention period
- ensure a 4cm gap is left in each box to allow easier removal and replacement of files
- do not send partially filled offsite storage boxes, these will be returned
- each box must be identified by a barcode
- a destruction date must be applied to the outside of the box and each file
Follow the instructions in this guidance (opens in new window)to order materials such as boxes and barcodes.
4.2 Patient files
Please ensure that 4.1 has been followed when prepping files for offsite storage.
Patient files relates to any file that has the patient’s name within.
Mixed files, with more than one patient’s details within a file, should not be sent to offsite storage as this makes it difficult to destroy when the retention period ends. If more than one patient is mentioned within a letter a copy of the letter should be placed on each patient’s file.
It is important that patient files are labelled inside the box correctly as the contents of patient file boxes are catalogued.
The files inside should each have:
- first name
- last or family name
- date of birth
- NHS number
- date of death (if applicable)
- the year sticker of last seen and the destroy date
Deceased and discharged records must be filed separately as they have different retention periods.
Where there are multiple files for the same service and individual, these should be placed in the same box wherever possible.
Do not band or tie files together, keep them separate.
Please make sure you place a file barcode on each file, and a box barcode on the outside of the box.
4.3 Staff files
Please ensure that 4.1 has been followed when prepping files for offsite storage.
The procedure for staff files is the same for patient files, however, the retention period differs. Please refer to the Records Management Code of Practice 2021 (opens in new window) for the correct retention period.
For each individual staff member’s file, the outside of the file must state:
- first name
- last or family name
- date of birth
- staff employee number
- destroy date
Do not band or tie files together, keep them separate.
Please make sure you place a file barcode on each file, and a box barcode on the outside of the box.
4.4 Other records
Please ensure that 4.1 has been followed when prepping files for offsite storage.
For any other records which are not patient or staff files but have a retention period greater than 1 year the following process under 4.1 should be adhered to.
4.5 Active patient records
Please ensure that 4.1 has been followed when prepping files for offsite storage.
The procedure for dealing with active patient records is the same for patient files. However, a destroy date cannot be used due to the patient still being alive and receiving treatment (destroy dates start at: date of discharge or date of death)
The files inside should each have:
- first name
- last or family name
- date of birth
- NHS number
Where there are multiple files for the same service these should be placed in the same box wherever possible.
Do not band or tie files together, keep them separate.
Please make sure you place a file barcode on each file, and a box barcode on the outside of the box.
4.6 New deposits and re-files
New deposits (records that have never been sent off-site) should be placed together in a box with other new deposits of the same destruction year.
Ensure the guidelines in 4.1 have been followed.
Re-files (records that have been retrieved from off-site) can be mixed in a box with other re-files. As long as the record has an offsite storage barcode on the cover.
4.7 File management
There will be occasions when it may be necessary to retrieve records that have been sent for storage. There is a cost associated with each retrieval therefore ensure there is a business need to retrieve a record. If unsure, refer to your manager.
Each service area should have members of staff who have access to the offsite storage facility to manage archived records, please liaise with this staff member over collections.
If the staff member has not logged on recently and requires a password reset, please contact rdash.recordsmanagement@nhs.net to arrange this.
If there is not a member of staff with access, please contact rdash.recordsmanagement@nhs.net to arrange this.
Follow the instructions in this guidance (opens in new window) to arrange collection.
Please note: the system will only work when opened in Internet Explorer.
Reasons you may need to retrieve a record could include:
- re-referral of patient
- re-employment of member of staff
- investigation
- subject access request
4.7.1 Re-referral of patient or re-employment of staff
Where the file is returning to the trust on a permanent basis and is being re-opened, for example the patient has been re-referred or the staff member has been re-employed, the record will need to be permed out from offsite storage.
In this instance, peel the existing barcode from the file and destroy it. Where the barcode cannot be removed without causing damage to the file, it must be blacked out with permanent marker to make it completely unreadable. Do not use a biro as the barcode could still be scanned through the biro ink.
Permed out means to be removed from the offsite storage database and then returned as a new file or new deposit.
At the point of discharge or termination of employment these records will be sent to offsite storage again following points 4.2 or 4.3.
4.7.2 Investigation or subject access request
Where the file remains closed, for example, the file is not needed for an investigation, or a subject access request files will need to be returned in the original box to the offsite storage facility using the existing barcode reference number.
Do not remove or amend existing barcodes on file(s) as this will make it difficult to track and return a file(s).
4.8 Delivery dates of retrievals
| Order submitted | Delivery day |
|---|---|
| Monday before 4pm | Wednesday |
| Monday after 4pm | Wednesday |
| Tuesday before 4pm | Wednesday |
| Tuesday after 4pm | Friday |
| Wednesday before 4pm | Friday |
| Wednesday after 4pm | Friday |
| Thursday before 4pm | Friday |
| Thursday after 4pm | Monday |
| Friday before 4pm | Monday |
| Friday after 4pm | Wednesday |
4.9 Re-referral
Where a patient has been re-referred back into the same service all records relating to a previous contact must be held on one file. Please follow 4.7 for file retrievals.
If records have been destroyed in line with the retention and disposal policy a new record or file must be created.
If the patient has had contact with another service, they will have a file in that service area. All files will be kept in accordance with the longest retention period but the service area files should not be mixed.
4.10 Filing
If there are a small number (a few pages) of outstanding papers for a file that is already at the offsite storage facility the file must be retrieved from the offsite storage and the information added to the file. The file can then be sent back to offsite storage.
Where loose filing exceeds a small amount an assessment needs to be made by the responsible team to decide whether a new file should be created: this is to ensure the box at offsite storage has enough space to accommodate the additional filing.
4.11 Destruction
On an annual basis records at offsite storage will be checked for any files that are ready for destruction. Reports will be generated, which will provide details of records to be destroyed.
After destruction the offsite storage provider will issue a destruction certificate to the DPO or head of information governance who will retain these for audit purposes.
4.12 Building closures
The data protection officer or head of IG must be notified immediately when it has been agreed a building is to close. This allows time to notify the current offsite storage provider that they may receive an influx of boxes within a set period of time.
Procedures must be followed in line with the moving to alternative premises policy.
Service areas must take responsibility for records and information generated for the service they have provided. The responsible managers must identify the types of records held and liaise with the data protection officer or head of IG regarding whether records are ready for destruction and are to be sent to offsite storage or another office before they vacate the building.
The relevant services must discuss the responsibility and ownership of the records with senior managers and agree how to manage the records effectively and safely.
Records must not be sent to another location without prior agreement with the data protection officer or head of IG.
Records must never be left in a vacated building regardless of whether it is still owned by the trust.
4.13 Quarantine
Where boxes of records do not conform to this procedure, records will be quarantined at offsite storage; questions will be raised and ultimately the boxes could be returned. Please make sure you factor enough time to archive your records correctly.
5 Appendices
5.1 Appendix A Offsite storage codes
Do not use DON, DOP or DSH.
If your code is not listed, please contact rdash.recordsmanagement@nhs.net.
| Account description | Level 1 account code |
|---|---|
| Rotherham, Doncaster and South Humber | 710 |
| RDASH workforce and OD other records | 710 |
| RDASH workforce and OD Staff files | 710 |
| RDASH finance other records | 710 |
| RDASH finance staff files | 710 |
| RDASH DSH medical director NCB | 710 |
| RDASH business assurance staff file | 710 |
| RDASH executive other records | 710 |
| Active patient files | 710 |
| Business assurance other records | 710 |
| RDASH AMH patient files | 710 |
| RDASH AMH other records | 710 |
| RDASH AMH staff files | 710 |
| RDASH forensics other records | 710 |
| RDASH forensics staff files | 710 |
| RDASH forensics patient files | 710 |
| RDASH DOP MH bus sup finance NCB | 710 |
| RDASH DOP MH bus sup finance NCF | 710 |
| RDASH DOP MH bus sup HR NCB | 710 |
| RDASH DOP MH bus sup HR NCF | 710 |
| Active patient files | 710 |
| RDASH OPMHS other records | 710 |
| RDASH OPMHS staff files | 710 |
| RDASH OPMHS patient files | 710 |
| RDASH SMS staff files | 710 |
| RDASH SMS other record | 710 |
| RDASH SMS patient file | 710 |
| RDASH LDS other records | 710 |
| RDASH LDS patient files | 710 |
| RDASH LDS staff files | 710 |
| RDASH DCIS patient files | 710 |
| RDASH DCIS staff files | 710 |
| RDASH DCIS other records | 710 |
| RDASH CYPMH other records | 710 |
| RDASH CYPMH patient files | 710 |
| RDASH CYPMH staff files | 710 |
| RDASH Warren nursery child files | 710 |
| RDASH Warren nursery staff files | 710 |
| RDASH DON CC bus sup finance NCF | 710 |
| RDASH DON CC bus sup finance NCB | 710 |
| RDASH DON performance NCB | 710 |
| Business assurance or health informatics | 710 |
| RDASH older peoples mental health | 710 |
| RDASH autism records | 710 |
| RDASH AMH recovery and social inclusion | 710 |
| Active patient records | 710 |
| CAMHS active patient records | 710 |
| DCIS active patient records | 710 |
| LDS active patient records | 710 |
| 710/48 DAS active patient records | 710 |
| Rotherham Borough wide | 710 |
| The Junction, TJ | 710 |
| Provider services | 710 |
| RDASH Doncaster MHA papers inactive | 710 |
| RDASH Doncaster MHA papers deceased | 710 |
| Mental Health Act papers inactive | 710 |
| Mental Health Act papers deceased | 710 |
| RDASH criminal justice liaison service | 710 |
| ANH admin or nurses home | 710 |
| CIT Community Intervention team | 710 |
| CNC community nursing central | 710 |
| CNE community nursing east | 710 |
| CNW community nursing west | 710 |
| CUB community urology and bowel S | 710 |
| DIA diabetes specialist | 710 |
| DIS district nurses | 710 |
| DNG directorate nursing. gov and Pa | 710 |
| GNP general (provider) | 710 |
| HFT Heart Failure team | 710 |
| HOS hospice | 710 |
| IMC intermediate care secretaries | 710 |
| OCC occupational therapy | 710 |
| POD podiatry services | 710 |
| SMO smoking cessations | 710 |
| SSP SCH service provision | 710 |
| SXH sexual health | 710 |
| The Junction JUN | 710 |
| The Junction TJ | 710 |
| Account description | Level 2 account code |
|---|---|
| Rotherham, Doncaster and South Humber | |
| RDASH workforce and OD other records | 0 |
| RDASH workforce and OD Staff files | 1 |
| RDASH finance other records | 2 |
| RDASH finance staff files | 3 |
| RDASH DSH medical director NCB | 4 |
| RDASH business assurance staff file | 5 |
| RDASH executive other records | 6 |
| Active patient files | 7 |
| Business assurance other records | 8 |
| RDASH AMH patient files | 9 |
| RDASH AMH other records | 10 |
| RDASH AMH staff files | 11 |
| RDASH forensics other records | 12 |
| RDASH forensics staff files | 13 |
| RDASH forensics patient files | 14 |
| RDASH DOP MH bus sup finance NCB | 15 |
| RDASH DOP MH bus sup finance NCF | 16 |
| RDASH DOP MH bus sup HR NCB | 17 |
| RDASH DOP MH bus sup HR NCF | 18 |
| Active patient files | 19 |
| RDASH OPMHS other records | 20 |
| RDASH OPMHS staff files | 21 |
| RDASH OPMHS patient files | 22 |
| RDASH SMS staff files | 23 |
| RDASH SMS other record | 24 |
| RDASH SMS patient file | 25 |
| RDASH LDS other records | 26 |
| RDASH LDS patient files | 27 |
| RDASH LDS staff files | 28 |
| RDASH DCIS patient files | 29 |
| RDASH DCIS staff files | 30 |
| RDASH DCIS other records | 31 |
| RDASH CYPMH other records | 32 |
| RDASH CYPMH patient files | 33 |
| RDASH CYPMH staff files | 34 |
| RDASH Warren nursery child files | 35 |
| RDASH Warren nursery staff files | 36 |
| RDASH DON CC bus sup finance NCF | 37 |
| RDASH DON CC bus sup finance NCB | 38 |
| RDASH DON performance NCB | 39 |
| Business assurance or health informatics | 40 |
| RDASH older peoples mental health | 41 |
| RDASH autism records | 42 |
| RDASH AMH recovery and social inclusion | 43 |
| Active patient records | 44 |
| CAMHS active patient records | 45 |
| DCIS active patient records | 46 |
| LDS active patient records | 47 |
| 710/48 DAS active patient records | 48 |
| Rotherham Borough wide | 49 |
| The Junction, TJ | CINTJ |
| Provider services | DON_1557 |
| RDASH Doncaster MHA papers inactive | 9 |
| RDASH Doncaster MHA papers deceased | 9 |
| Mental Health Act papers inactive | 9 |
| Mental Health Act papers deceased | 9 |
| RDASH criminal justice liaison service | 9 |
| ANH admin or nurses home | DON_1557 |
| CIT Community Intervention team | DON_1557 |
| CNC community nursing central | DON_1557 |
| CNE community nursing east | DON_1557 |
| CNW community nursing west | DON_1557 |
| CUB community urology and bowel S | DON_1557 |
| DIA diabetes specialist | DON_1557 |
| DIS district nurses | DON_1557 |
| DNG directorate nursing. gov and Pa | DON_1557 |
| GNP general (provider) | DON_1557 |
| HFT Heart Failure team | DON_1557 |
| HOS hospice | DON_1557 |
| IMC intermediate care secretaries | DON_1557 |
| OCC occupational therapy | DON_1557 |
| POD podiatry services | DON_1557 |
| SMO smoking cessations | DON_1557 |
| SSP SCH service provision | DON_1557 |
| SXH sexual health | DON_1557 |
| The Junction JUN | CINTJ |
| The Junction TJ | CINTJ |
| Account description | Level 3 account code |
|---|---|
| Rotherham, Doncaster and South Humber | |
| RDASH workforce and OD other records | |
| RDASH workforce and OD Staff files | |
| RDASH finance other records | |
| RDASH finance staff files | |
| RDASH DSH medical director NCB | |
| RDASH business assurance staff file | |
| RDASH executive other records | |
| Active patient files | |
| Business assurance other records | |
| RDASH AMH patient files | |
| RDASH AMH other records | |
| RDASH AMH staff files | |
| RDASH forensics other records | |
| RDASH forensics staff files | |
| RDASH forensics patient files | |
| RDASH DOP MH bus sup finance NCB | |
| RDASH DOP MH bus sup finance NCF | |
| RDASH DOP MH bus sup HR NCB | |
| RDASH DOP MH bus sup HR NCF | |
| Active patient files | |
| RDASH OPMHS other records | |
| RDASH OPMHS staff files | |
| RDASH OPMHS patient files | |
| RDASH SMS staff files | |
| RDASH SMS other record | |
| RDASH SMS patient file | |
| RDASH LDS other records | |
| RDASH LDS patient files | |
| RDASH LDS staff files | |
| RDASH DCIS patient files | |
| RDASH DCIS staff files | |
| RDASH DCIS other records | |
| RDASH CYPMH other records | |
| RDASH CYPMH patient files | |
| RDASH CYPMH staff files | |
| RDASH Warren nursery child files | |
| RDASH Warren nursery staff files | |
| RDASH DON CC bus sup finance NCF | |
| RDASH DON CC bus sup finance NCB | |
| RDASH DON performance NCB | |
| Business assurance or health informatics | |
| RDASH older peoples mental health | |
| RDASH autism records | |
| RDASH AMH recovery and social inclusion | |
| Active patient records | |
| CAMHS active patient records | |
| DCIS active patient records | |
| LDS active patient records | |
| 710/48 DAS active patient records | |
| Rotherham Borough wide | |
| The Junction, TJ | |
| Provider services | |
| RDASH Doncaster MHA papers inactive | D24 |
| RDASH Doncaster MHA papers deceased | D25 |
| Mental Health Act papers inactive | R24 |
| Mental Health Act papers deceased | R25 |
| RDASH criminal justice liaison service | R26 |
| ANH admin or nurses home | ANH |
| CIT Community Intervention team | CIT |
| CNC community nursing central | CNC |
| CNE community nursing east | CNE |
| CNW community nursing west | CNW |
| CUB community urology and bowel S | CUB |
| DIA diabetes specialist | DIA |
| DIS district nurses | DIS |
| DNG directorate nursing. gov and Pa | DNG |
| GNP general (provider) | GNP |
| HFT Heart Failure team | HFT |
| HOS hospice | HOS |
| IMC intermediate care secretaries | IMC |
| OCC occupational therapy | OCC |
| POD podiatry services | POD |
| SMO smoking cessations | SMO |
| SSP SCH service provision | SSP |
| SXH sexual health | SXH |
| The Junction JUN | JUN |
| The Junction TJ | TJ |
Document control
- Version: 4.1.
- Unique reference number: 331.
- Ratified by: Corporate policy approval group.
- Date ratified: 29 January 2024.
- Name of originator or author: Data protection officer or head of information governance.
- Name of responsible individual: Data protection officer or head of information governance.
- Date issued: 8 February 2024.
- Review date: February 2025.
- Target audience: All RDaSH employees.
Page last reviewed: April 15, 2024
Next review due: April 15, 2025