The Independent Health Care Regulations (Northern Ireland) 2005

Records

21.—(1) The registered person shall ensure that –

(a) a comprehensive medical record is maintained in relation to each patient, which includes –

(i) a contemporaneous note of all treatment provided to him;

(ii) his medical history and all other notes prepared by a health care professional about his 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 shall ensure that –

(a) the medical record for a person who is currently a patient is kept in a secure place in the establishment or the agency premises; and

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

(3) The registered person shall ensure that the records 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 the agency premises by any person authorised by the Regulation and Improvement Authority to enter and inspect the establishment or agency premises; and

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