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How long should you keep medicine charts for – CQC

How long should you keep medicine charts for – CQC

In summary

CQC updated their advice on medicines records and made the following change:

Q: How long should you keep medicines charts for?

A: Previously 3 years, now it’s 8 years.

The update from CQC (1) is a little lengthy, and if you are busy it can be a lot to digest, so we’ve condensed it down here for you.

The key points:

Their advice mostly repeats existing knowledge about medicines charts. Most of which we’ve already published on previous updates (click here to read) However, at the end of the CQC mention an important update:

  • Keep medicines administration records for at least 8 years after the person’s care ended at the service. After 8 years, review the records”

Q: What is meant by medicines records?

A: By medicines records, we mean MAR charts, body maps, PRN protocols etc. This applies to paper and electronic records. Note that CD registers only need to be kept for 2 years after date of last entry.

Background
CQC reference this document: Records Management Code of Practice for Health and Social Care. Published by NHS England in August 2021. This code applies to all health and care records, but here we’ll focus on medicines records.

The document has is a large table with various record types and their retention periods. Medicines records aren’t really mentioned, however there is a “all other records” box which states 8 years. This is what CQC went with.

Q: When does the 8-year period start?

For example, if you start caring for someone from 2013 to 2023, do you:

a) keep records from 2013 to 2023 plus 8 years (i.e. 18 years of records from 2013 to 2031) or
b) keep records from 2023 plus 8 years (i.e. 8 years of records from 2023 to 2031)

A: It’s b) as the code states the retention period begins “when the record ceases to be operational”

Q: Can you destroy the records after 8 years?

The code says you have to review them first and states a number of reasons why you might want to keep them longer. Looking at the list, the only really relevant bullet point for medicines records is:

• Serious incidents which will require records to be retained for up to 20 years

A: Our advice is if you had a medication error that caused death or serious harm, keep these medicines records for 20 years, if not destroy them (in a way that preserves confidentiality) after 8 years.

We provide a course that teaches how to compile an accurate list of a person’s medicines (called ‘medicines reconciliation’) and how to enter this information onto paper or electronic medicines charts (called ‘medicines transcription’) for details: click here.

References

  1. https://www.cqc.org.uk/guidance-providers/adult-social-care/medicines-administration-records-adult-social-care

John Greene
Lead Pharmacist and MD
The Medication Training Company