GP Records on line!

COMMENTS – If you have any Comments on this post please email  robert.campbell@kingfisherpm.com.

Records on line

NHS patients are to be offered access ‘on line’ to their GP medical record. Only a small number of GP practices so far have set up their computer system for their patients and clearly there is a long way to go before such a service is widely available. Whilst patients do have a legal right to access their records it is still quite unusual for patients to ask to see their record. For practices it is usually quite a palaver which involves a written request and arrangements made to view the hand held record and the computer record under supervision. Doctors, however, often turn the computer screen towards a patient so that they can see what is on the screen.

In the last two years the sharing of records within the NHS has actively been encouraged. Patients have been asked to agree to sharing in and sharing out of their GP records. Consent has been required. However, the anonymous sharing of records has not required patient consent.  The exercise to ‘get’ consent is enormous and time consuming.

Access requests

The requests for access are rare and are usually associated with a complaint or litigation. Attitudes amongst doctors vary on allowing access and understanding the law about access. Patients are entitled to see the whole of their record unless a GP has a sound reason tested in a court of law not to do so. Copies of NHS records are often sought to support insurance or accident claims and again the approach taken by practices varies. Some GPs like to review a record before it is copied. Care should be taken to ensure that the content of the record is such that a GP would be happy with the information contained being shared with the patient and a third party. This whole process can be quite time consuming and the practice has 40 days to respond (and often takes it) Copying records can be a nuisance so to allow computer access to records would save time and expense.

Quality of Records

It could be said that since the introduction of READ codes and computer records greater care has been taken on keeping records, organizing their content and standardizing the content. The use of ‘free text’ in records is always to be discouraged. The use of abbreviations and of standard phrases that could be open to different interpretations is also discouraged. However the complexities of coding systems can make record keeping even more difficult. Beware of the ‘delete’ button. Adding information to computer records after the event can also be traced – so making late claims or changing a record to fit is not advisable.

Keep it Simple

Records should simply record the health history of the patient in clear and simple terms that are understandable by the reader whether the reader is a patient or a health professional. To use modern medical language it needs to record the clinical encounters and interventions. This means that it should record consultations (with whom) and treatment and care prescribed. It should also include any allergies and routine repeat prescriptions associated with the patient. The record should include copies of all test results and clinical letters received from any hospital associated with the patients care.

COMMENTS – If you have any Comments on this post please email  robert.campbell@kingfisherpm.com.

Robert Campbell is retired practice manager and has used both EMIS and Systm One GP Clinical systems

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