Medical Records - Adopted Children
Under adoption legislation, an adopted child is given a new NHS number, and all previous medical information relating to that child is put into a newly created health record. Any information relating to the identity or whereabouts of the birth parents should not be included in the new record. The change of name, NHS number and transfer of previous health information into a new health record should take place for both GP records and hospital records. There should not then be any difficulty in obtaining information about the child's previous treatment in secondary care.
Whilst changing or omitting information from medical records would usually be contrary to ethical and professional guidance this is not the case for the records of adopted children as there is a legal requirement that it takes place.
The pre-adoptive information should be regarded as confidential and the practice must ensure that robust systems are in place for access or disclosure. Different clinical systems have employed different solutions and if you are unsure of what is in place in your clinical system then you should speak to your clinical supplier regarding this situation. By logging a call to their helpdesk you will establish an audit trail which confirms how the scanned records containing 'old details' are managed by them.
We have updated and amended a previously shared suggested practice protocol for dealing with a patient who undergoes adoption that you may wish use and adapt for your practice processes.
PCSE now deal with the movement of adoption records on behalf of NHSE.