Additional services records in community pharmacy

Record description

Records created during Appliance Use Reviews (AURs), including assessments, recommendations, outcomes and payment verification.

Minimum retention time

• retain records required for reimbursement purposes for at least 12 months
• retain clinical records relating to adults aged 18 years and over for at least 8 years
• retain clinical records relating to children until their 25th birthday or until their 26th birthday if they were 17 years when the treatment ended

Supporting source

The Pharmaceutical Services (Advanced and Enhanced Services) (England) Directions 2013 require records to be retained for a minimum period of 12 months or for longer if reasonably required by NHS England.

CPE advise on the retention of clinical records during AURs.

Record description

Records such as blood pressure readings, referrals and service claims.

Minimum retention time

• retain records required for reimbursement purposes for at least 3 years
• retain clinical records relating to adults aged 18 years and over for at least 8 years

Supporting source

CPE advise on the retention of clinical records and records for reimbursement.

Record description

Records such as consent, pre-vaccination assessments, vaccine administration and batch details, and service claims.

Minimum retention time

• retain records required for reimbursement purposes for at least 3 years
• retain clinical records relating to adults aged 18 years and over for at least 8 years
• retain clinical records relating to children until their 25th birthday or until their 26th birthday if they were 17 years when the treatment ended
• retain clinical records relating to women who a pregnant until the child’s 25th birthday

Supporting source

The RMCoP advise treating pharmacy vaccination service records in the same way as patient records.

CPE advise on the retention of clinical records and records for reimbursement.

Record description

Records such as consultations, pharmaceutical care, clinical intervention, referrals and service claims.

Minimum retention time

• retain records required for reimbursement for at least 2 years from the date the service is completed or discontinued

Supporting source

The Pharmaceutical Services (Advanced and Enhanced Services) (England) Directions 2013 require records to be retained for a minimum period of 2 years.

CPE advise on the retention of records for reimbursement.

Record description

Records such as cardiovascular risk, lifestyle advice, referrals and follow-ups.

Minimum retention time

• retain records for at least 8 years from the last patient interaction

Supporting source

The NHS Health Check Best practice guidance (Oct 2019) does not give record retention times.

The RMCoP advise treating clinical pharmacy records in the same way as patient records.

Record description

Records such as consultations, clinical assessments, medicine supply, referrals and service claims.

Minimum retention time

• retain records required for reimbursement purposes for at least 3 years
• retain clinical records relating to adults aged 18 years and over for at least 8 years
• retain clinical records relating to children until their 25th birthday or until their 26th birthday if they were 17 years when the treatment ended

Supporting source

NHS England Pharmacy First guidance does not give record retention times.

CPE advise on the retention records for reimbursement.

The RMCoP advise treating clinical pharmacy records in the same way as patient records.

Record description

Records such as campaign activity, information provided and service monitoring.

Minimum retention time

• retain records for at least 2 years

Supporting source

CPE guidance does not give record retention times.

The RMCoP has been interpreted to treat these records similar to prescription records for the purpose of audit and service assurance.

Record description

Records such as emergency contraceptive consultations, contraceptive supply, referral and service claims.

Minimum retention time

• retain records required for reimbursement purposes for at least 3 years
• retain clinical records relating to adults aged 18 years and over for at least 8 years
• retain clinical records relating to children until their 25th birthday or until their 26th birthday if they were 17 years when the treatment ended
• retain records relating to implants or devices for at least 10 years

Supporting source

The Council Directive 93/42/EEC of 14 June 1993 states records relating to implantable devices in general should be kept for a minimum of 15 years.

The RMCoP advises sexual health service records be treated like clinical records. It also advises a minimum of 10 years for records relating to contraceptive implants or devices. This advise supports the licensed duration for some long-acting reversible contraceptive (LARC) devices.

CPE advise on the retention of records for reimbursement.

Record description

Records such as assessments, smoking status, follow-up, referral and service claims.

Minimum retention time

• retain records relating to the non-prescription supply of nicotine replacement therapy (NRT) for at least 2 years
• retain records required for post-payment verification (PPV) for at least 3 years
• retain clinical records relating to adults aged 18 years and over for at least 8 years

Supporting source

CPE advise on the retention of clinical and PPV records.

The RMCoP has been interpreted to treat records relating to the supply of NRT similar to pharmacy prescription records.

Record description

Records such as customisation requests, assessments, appliance modifications, appliance supply, and service claims.

Minimum retention time

• retain records required for reimbursement purposes for at least 12 months
• retain clinical records relating to adults aged 18 years and over for at least 8 years

Supporting source

CPE advise on the retention of clinical records and records for reimbursement.

Record description

Records such as supervised consumption, needle exchange, referrals and clinical notes.

Minimum retention time

• retain records for at least 2 years
• retain clinical records relating to adults aged 18 years and over for at least 8 years

Supporting source

CPE guidance does not give record retention times.

The RMCoP has been interpreted to treat records relating to the supply similar to pharmacy prescription records. Clinical records should be treated as patient records.