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Accurate and well-maintained medical records are the backbone of effective hospital care. From documenting patient histories to supporting clinical decisions and ensuring continuity of care, medical record keeping plays a pivotal role in modern healthcare systems. It’s not just about paperwork—it’s about accountability, communication, and safeguarding patient welfare.
In this article, we explore everything you need to know about medical record keeping in hospitals. We begin by clarifying what constitutes a medical record and why it holds such immense value. We then examine the core principles of good record keeping, the storage and organisation of case notes, the importance of a reliable master index, and the function of the medical record library. You’ll also find guidance on departmental procedures and best practices for retention and destruction of records.
Whether you’re managing records, working in clinical administration, or simply aiming to understand the framework that underpins hospital documentation, this guide offers a detailed look at how hospitals keep information orderly, secure, and accessible when it matters most.
Table of Contents
What is a Medical Record?
A medical record is a document that details a patient’s medical history at a certain institution, including prescription drugs, tests, and appointments. The most recent or current hospital medical record should contain the patient’s record from any other hospital where they received treatment.
A comprehensive record helps prevent duplications and facilitates future care. The GP’s records are typically the most comprehensive. This is due to the fact that they track the patient’s geographic movements. Additionally, the record includes correspondence, previous diagnoses and treatments, completed tests and analysis, and any other pertinent data.
The Value of Medical Records
Medical records serve as formal documentation, a communication tool, and a reminder for physicians and nurses. They provide details on the type of drug or treatment received, the dosage and duration, the method of administration, and the results.
Medical records are frequently used for research as well as teaching medical students.
Principles of Good Record Keeping
Records should be taken in a specific way:
- Legible handwriting is essential. Except for notes taken for theatre or pharmacy/drug charts, which call for green ink, a black pen should be used.
- The name and work title of the writer must be included with every entry, along with their signature.
- The time and date must be included in every entry.
- It is necessary to number the pages.
- Every page should include the patient’s name and NHS number.
- Documents ought to be factual only.
- Note any prescription drugs and therapies administered.
- Add any tests, evaluations, and reviews completed, as well as any plans made for follow-up care.
- Add any guidance you may have offered the patient.
- Any problems (such as those involving the patient or the treatment) should be documented, along with your strategy for resolving them.
- Records cannot be destroyed or altered unless specifically instructed to do so by a person with the necessary authorisation.
- In the rare event that you need to make changes to a medical record and you have been given permission to do so, you must write your name and work title on the original document before signing, dating, and timing it.
- Everyone, not just yourself, should be able to read the words you employ.
- Documents must be readable when photocopied or scanned.
- You are not allowed to lie or falsify anything in records.
Storage of Medical Records
Every hospital will have a different method for keeping medical records based on what works best for them.
There are three main methods commonly used:
- System of adjacent files. This is the arrangement of files side by side on a shelf.
- System of upright filing. At this point, files are kept in cabinets with multiple drawers.
- Carousel filing systems that rotate. These are often good space-savers and spin around.
Patient confidentiality makes the security of the location where medical records are stored crucial, regardless of the file system utilised.
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Case Notes
When the NHS was established, a uniform structure for medical records was provided to guarantee uniformity. Nonetheless, many hospitals still have different record-keeping practices based on what works best for them.
Medical records typically have a same general format. Usually packaged in A4-sized folders, they are divided into five sections:
Identification: This contains the patient’s name, occupation, NHS number, date of birth, address, phone number, and hospital name and code number. Information about their next of kin, parents’ religion, and general practitioner will also be included.
Medical: The history of the current complaint, the patient’s past medical history (PMH), family history, patient complaints (PCO), examination results (OE), differential diagnosis, investigations, and treatment are typically included in this part, which is exclusively for the doctor’s use.
Nursing: Only when patients are admitted are nursing staff observations recorded in this section. It includes the patient’s temperature, pulse, and respiration (TPR), the nursing record, and charts for intake and outflow (all fluids consumed orally, through transfusion, or through excretion).
Correspondence: The GP’s referral letter or pro forma referral, the consultants’ reports to the GP, and any additional correspondence to and from other professionals or consultants are all included in this part.
Results: Prescription charges, social history, theater/surgical procedure sheets, consent papers, and anaesthesia paperwork may also be included in the records.
Master Index
There should only be one medical record for each patient. However, it might be perplexing when a single patient has several problems or therapies. Additionally, a law mandates that patients who visit a genitourinary clinic—which deals with the genitalia or urinary organs—have a separate file that is maintained apart from their primary medical records.
The location and timing of the patient’s mental care are noted in the primary medical record, and psychiatric medical records are often kept apart.
‘Master index’ is a document designed to minimise the number of patients with multiple medical records. This alphabetical list of hospitalised patients can be stored on cards and manually filed, or it can be stored on an optical disc, microfiche, microfilm, or computer.
Information such as names, sex, date of birth, home address, and marital status are typically included in the master index. The patient index number, religion, date of death, and the date of initial attendance and consultations are occasionally included.
Medical Record Library
All of the medical records for that particular hospital are kept in the medical record library. Because records pile up quickly and are heavy, it is most frequently seen on the ground floor.
Due to the large amount of sensitive data that needs to be protected, the area will be well secured. To enter the area, staff members will need permission.
The files in this library will be meticulously arranged. Although there are several options, the majority of hospitals use the patient master index to store their medical records. Additionally, colour coding is frequently utilised to make the filing system appear tidy and well-organised.
Medical Record Procedures for Departments
Accident and Emergency Records
Here is an example of what happens when a patient arrives at the hospital:
- The patient arrives in an ambulance. Any information the ambulance driver can find about the patient is entered into the book.
- A medical secretary looks up any prior documentation.
- Whether or not the medical records are located in time, treatment starts. If the primary medical records are not available, an A&E record will be created.
- If the patient is unconscious or has no family, a follow-up will be conducted to gather information.
- Any patient belongings, such as a pocketbook or keys, will be noted by nurses (or a receptionist with a witness).
- The departments are informed if the patient’s medical records are located and whether they have any appointments at the hospital. Additionally, as soon as practicable, next of kin are notified.
Outpatient Records
- Outpatients who receive a formal referral from their general practitioner are welcome to attend the hospital.
- Information on the patient will be included in the letter to aid in locating any additional medical documents.
- An appointment will be set up after the letter is delivered to the senior registrar or consultant of the relevant department. Their appointment will be scheduled sooner if the problem is more urgent. Following that, a list will be created for each clinic, and all scheduled patients’ medical records will be prepared.
- They are brought together, or in ‘pulling’ order, to generate a copy of the list. A copy of the list will be sent to the person getting ready for the clinic, who will then need to get the lab work, medical records, and other items that were requested during the last appointment. The medical records must contain these findings.
- To make sure there is enough paper to write on, the medical records are also examined. Additionally, they need to be typed up or stamped with the clinic’s consultant and date.
- In order to conserve time and paper, case notes for patients who are visiting the hospital for the first time will only be partially completed. Until the patient shows up, the information is not verified.
Day-Case Records
- The department or ward in question is usually in charge of these records.
- Prior to the patient’s arrival, the medical records department is contacted to obtain the medical records.
- The remaining steps are the same as for outpatient records.
Maternity Records
Most of the time, a woman keeps her maternity records during her pregnancy, and the hospital only keeps them once she is admitted to give birth.
Admissions and Transfers
- Every day, the ward receives a list of names for everyone who is anticipated there, so they know who to expect.
- In order to provide the patient’s medical records to the ward in advance of their arrival, the list is also forwarded to the records library.
Retention and Destruction of Records
Different records are kept for different periods of time:
- Records pertaining to obstetrics (childbirth). 25 years or 8 years following the child’s death, but not the mother’s
- Young folks and children. until the patient turns 25; if the entry was made when the young person was 17, it will be on the 26th; if it is earlier, it will be on the 8th after death (10 years for physician records).
- Mental health sufferers. Eight years after death, or twenty years after therapy is no longer deemed required (10 years for GP records).
- All further private medical records. 8 years following treatment completion (10 years for GP records).
Destruction of Medical Records
Medical record departments will have a written destruction policy which will be agreed upon by the clinical and administrative staff.
Destruction of medical records can only be carried out by people who are authorised to do it in accordance with the written policy. This is usually done by incineration or shredding. Destruction must also be monitored to ensure confidentiality. A record of the instruction to destroy the records should be retained.
Conclusion
Medical record keeping in hospitals is far more than a bureaucratic necessity—it is a critical function that supports safe, informed, and coordinated healthcare. Each stage, from initial documentation to long-term storage and eventual destruction, is governed by procedures that reflect the need for accuracy, security, and accountability. Whether stored in paper folders or digital formats, these records shape patient journeys and provide the foundation for effective clinical practice.
Understanding how these records are structured, accessed, and maintained helps ensure that patients receive the continuity and quality of care they deserve. It also supports professionals in meeting legal, ethical, and organisational standards. By adhering to clear principles and departmental protocols, hospitals can manage information efficiently while safeguarding one of the most sensitive assets they hold: patient trust.
Frequently Asked Questions
How long are hospital medical records kept in the UK?
According to NHS guidelines and best practice, the retention period varies depending on the type of record. For example, maternity records are typically kept for 25 years, children’s records until their 25th birthday, and general medical records for 8 to 10 years after treatment ends. Mental health records may be retained up to 20 years or 8 years after death, whichever is longer.
Who is allowed to access hospital medical records?
Access to hospital records is strictly controlled. Only authorised healthcare professionals involved in the patient’s care, medical records staff, or administrative staff with legitimate reasons may view them. Under the Data Protection Act and GDPR, patients also have the legal right to access their own records upon written request.
What is the purpose of a master patient index in hospitals?
The master patient index (MPI) is a critical tool used to avoid duplicate records. It contains unique identifying details for every patient who has received hospital care. The MPI helps staff retrieve patient records quickly and ensures continuity of care across departments by linking various treatments under one patient identity.
How are paper medical records safely stored in hospitals?
Hospitals use secure filing systems like adjacent shelving, vertical cabinets, or rotating carousels, often in restricted-access medical record libraries. These areas are monitored and require staff authorisation for entry. Confidentiality is upheld through strict handling protocols and proper training in data protection.
What happens to medical records after a patient dies?
After a patient’s death, their records are typically retained for a specified period depending on the record type—ranging from 8 to 25 years. After this, records may be destroyed securely (usually via shredding or incineration), but only with documented authorisation and in compliance with a formal destruction policy to protect patient confidentiality.
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