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Records Management

ADHD Plus Health is committed to maintaining accurate, appropriate and secure records relating to patient care.

Clinical Records

A clinical record may include:

  • Patient details
  • Medical and mental health history
  • Assessment documentation
  • Screening questionnaires
  • Consultation notes
  • Diagnostic information
  • Treatment plans
  • Prescribing records
  • Medication monitoring
  • Clinical reports
  • Referral information
  • Relevant emails and communications
  • Correspondence with GPs or healthcare professionals
  • Consent documentation
  • Safeguarding information where relevant

Accuracy of Records

Healthcare professionals are expected to maintain records that are appropriately accurate and sufficiently detailed to support safe and effective care. Patients should inform ADHD Plus Health if their personal details change. Where a patient believes factual personal information is inaccurate, they may contact us to request that it is reviewed. Clinical opinions or professional observations will not necessarily be removed solely because a patient disagrees with them, although appropriate clarification or additional information may be recorded where required.

Security

Patient records must be stored securely. Access should be limited to individuals who require information for legitimate clinical, administrative, legal or regulatory purposes. Reasonable safeguards may include:

  • Access controls
  • Password protection
  • Secure clinical systems
  • Staff confidentiality requirements
  • Appropriate technical security
  • Secure backup arrangements

Record Retention

Clinical records will be retained for periods appropriate to the type of record and applicable legal, regulatory, professional and clinical requirements.

Records will not be retained indefinitely where there is no lawful or legitimate reason to keep them.

Access to Records

Patients may have the right to request access to personal information held about them. Requests should be sent to:

Identity verification may be required before information is released. Certain information may be withheld where permitted or required by law, including information relating to another person or information whose disclosure is subject to a lawful exemption.

Sharing Records

Clinical information may be shared where appropriate with healthcare professionals or organisations involved in the patient’s care. Information may also be disclosed where required by law or where serious safeguarding or safety concerns exist.

Disposal of Records

When records reach the end of the approved retention period, they will be securely destroyed or deleted in accordance with applicable requirements.