Issues for clinical records

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Standards for computer records

  • 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.
  • Sophie templates should be used where available.
  • All significant events should be entered on computer including investigations, operations Clinical summaries are produced automatically
  • Clinical notes
  • Should be contemporaneous
  • Clinical entry should contain:
  • date (automatic)
  • type of encounter eg surgery, home visit, telephone call
  • diagnosis or definition of problem – the current problem
  • management plan
  • treatment prescribed: all prescribing should be computer based
  • information given to patient
  • follow up plan

Patients’ access to records

  • 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

Records and confidentiality

  • 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.
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