Medical Records - Adopted Children

Medical Records - Adopted Children (with acknowledgements to Wessex LMCs)

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.

To go through a patient's computer notes and ensure that there is no reference to previous identity is onerous. Most clinical systems have the functionality to place 'old' information into the `history/archive' section of the patient's medical record - and this would comply with the NHS Central Register requirements that it must be retained for future reference.  This information would not be 'on view' for any of the main screens used by the staff employed or attached to general practice when carrying out their normal duties but, dependent upon the security access rights attached to GPs and staff, appropriate individuals could have access.

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.

A suggested protocol for dealing with the record of a patient who undergoes adoption is available under this section in the Wessex LMCs website, with thanks to the Quarter Jack Practice at Wimbourne, Dorset.