Regulation 23 RecordsI1

England and Wales

(1)

The registered person must ensure that except in cases to which regulation 43(5) applies—

(a)

a comprehensive health care record which may be in paper or electronic form is maintained in relation to each patient, which includes—

(i)

a contemporaneous note of all treatment provided to the patient;

(ii)

the patient’s medical history and all other notes prepared by a health care professional about the patient’s case; and

(b)

the record is retained for a period which is not less than that specified in Part I of Schedule 3 in relation to the type of patient in question or, where more than one such period could apply, the longest of them.

(2)

The registered person must ensure that—

(a)

the health care record for a person who is currently a patient is kept in a secure place in the establishment or agency premises; and

(b)

the health care record for a person who is not currently a patient is stored securely (whether in the establishment or agency or elsewhere) and that it can be located if required.

(3)

In addition to the health care records maintained in accordance with paragraph (1), the registered person must ensure that the records, which may be in paper or electronic form, specified in Part II of Schedule 3 are maintained and that they are—

(a)

kept up to date;

(b)

at all times available for inspection in the establishment or agency by any person authorised by the registration authority to enter and inspect the establishment or agency; and

(c)

retained for a period of not less than three years beginning on the date of the last entry.

(4)

Where an establishment or agency closes the registered person must ensure that the records maintained in accordance with paragraphs (1) and (3) are kept securely elsewhere and must make them available for inspection by the registration authority at its request.

Annotations

Commencement

I1: Reg. 23 in force at 5.4.2011, see reg. 1(1)