Clinical entries should be made in a problem-orientated fashion
on the current screen
clinical entries should always be made on computer under the
appropriate current problem
prescriptions should always be produced on computer under the
appropriate current problem
all important Read codes are automatically summarised by the
computer
Clinical entries should never be made in the unlinked section
Referrals codes are always entered by the referrer under
an appropriate current problem heading.
All referrals should have a referral code
All referral letters are generated by System 6000
and attached to this code
All referral codes are
audited monthly for attachments to pick up missed
referrals
Incoming correspondence
Filing test results performed electronically
Scanning
Summarising records
Home visit reports are printed out if required, and always
for a visit not performed by the patients usual doctor (eg
holidays, GP registrar)
Entries will be made for face to face consultations,
telephone consultations, out of hours advice and all home
visits. Home visit records should be entered on return to
the surgery.
Adverse reactions and sensitivities to drugs are entered into
the record.
Patients can normally see their computer record in the consulting
room, though care has to be taken when people other than
the patient are present in the room.
Patients have access to their written and computer
records if requested, although the records may not be
removed form the practice premises. Assistance is given
by the practice manager if access is required to the
computer record and in this circumstance a member of
staff will stay with the patient at all times. If copies
or a computer printout are required, a charge is made for
this to cover costs incurred.
Patient advice on accessing
their medical health records
Access to clinical records is on a "need to know"
basis.
PHCT members have access to clinical and computer
records for appropriate use relating to that
patient's care or to assist in the understanding
of family problems with which they are involved.
Types of access to the computer record are
defined according to need (individual levels of
access according to user configuration).
Access is given to relevant clinicians outside
the PHCT only with explicit consent.
Access is given to other agencies only with the patient's
express written consent.
Original records are never sent by post, any copies
of records sent (eg legal requests) are sent by secure
post.
Data sent from the practice or on the website is anonymised
and care is taken that patients could not be identified from
within this data.
The clinical computer system is passworded.
Passwords are only known to the individual.
Passwords are changed regularly.
Patient record screens should never be left live
- screen should be locked or system logged
off if the user leaves the terminal.
The clinical computer system is enabled so that
individual entries may be defined as doctors only
or user only.
