For the NHS secondary care the answer includes:
"No-one knows if it is legally OK to only have computerised records"
"Burton have already done this"
"It is not knwon when definitive guidance will be available"
(For primary care it is already legally OK)
Dr Jonathan Kay
On Thursday, August 22, 2002, at 02:06 , Graham, Billy wrote:
> Hi Jeffrey,
>
> Thanks for your reply and all those others I have received both via the
> list
> and direct to my e-mail address.
>
> I notice in the text you quoted that...
> "Diagnostic records are properly retained in individual patient notes
> or in
> electronic form..."
> the bit I am interested in is the OR word...
> "Diagnostic records are properly retained in individual patient notes
> OR in
> electronic form..."
>
> Does this mean it can be an either/or situation as I interpret it from
> your
> quote?
> In other words if the ward have their 'Diagnostic records', which I
> assume
> covers lab reports, stored in electronic form (in most cases on
> laboratory
> computer) they can dispose of the hard-copy reports (which brings me
> back to
> the original question).
>
> Regards, Billy.
>
>
>
>
> -----Original Message-----
> From: Jeffrey Davies [mailto:[log in to unmask]]
> Sent: 22 August 2002 13:45
> To: Graham, Billy; [log in to unmask]
> Subject: Re: Retention of printed lab reports by wards
>
>
> Dear Billy,
> The College guidelines summarise admirably:
> "Diagnostic records are properly retained in individual patient notes
> or in
> electronic form, the safe keeping of which is the responsibility of
> hospital
> records departments or recipient general practitioners or private
> practitioners, once the pathologist has issued the reports. Where
> pathologists have reason to doubt the reliability of systems of patient
> record keeping, they should bring this to the attention of those
> responsible rather than attempt to rectify it by duplication and local
> and
> prolonged laboratory storage of diagnostic records."
> The practice you describe is appalling and should be reported to your
> hospital management.
> Regards,
> Jeff Davies
>
>>>> "Graham, Billy" <[log in to unmask]> 08/21/02 04:52pm >>>
> Hi,
>
> Does anyone have information on how long wards must legally keep
> hard-copy
> laboratory reports, if at all, assuming they will always be available
> electronically via the lab computer (both active and historical
> records).
> This query came to me from the nursing staff. Currently the ward in
> question
> receives lab reports and the nurses filter out any showing 'abnormal'
> results. The medical staff then look up these patient records in the lab
> computer and take appropriate action. Following this, all the hard-copy
> reports are filed away alphabetically in boxes dating back 7 years - the
> reports are NOT stored with the patient record. These hard-copy
> archives are
> taking up a lot of room and much staff time in operation of the filing
> system.
>
> I think if the retention of the hard copies is not a legal requirement
> the
> ward would like to file them in the drawer labelled 'bin' rather than
> waste
> time and space filing them as they currently do.
>
> Any advice would be much welcomed.
>
> Best regards, Billy Graham.
>
>
>
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