Private and Voluntary Health Care (Wales) Regulations 2002

Records

20.—(1) The registered person shall ensure that except in cases to which regulation 39(5) applies—

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

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

(ii) the patient’s medical history and all other notes prepared by a health care professional about the patient’s 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 premises; and

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

(3) In addition to the medical records maintained in accordance with paragraph (1), 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 by any person authorised by the National Assembly to enter and inspect the establishment ; and

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

(4) Where an establishment closes the registered person shall ensure that the records maintained in accordance with paragraphs (1) and (3) are kept securely elsewhere and shall make them available for inspection by the National Assembly at its request.