The National Health Service (General Medical Services) (Scotland) Amendment (No.2) Regulations 1999

32Records

1

In this paragraph, “computerised records” means records created by way of entries on a computer.

2

Subject to sub-paragraphs (4) and (5), a doctor shall keep adequate records of the illnesses and treatment of his patients providing such details as the Secretary of State may from time to time determine after consultation with an Organisation which is in his opinion representative of the general body of doctors, and shall do so—

a

on forms supplied to him for the purpose by the Health Board; or

b

by way of computerised records,

or in a combination of those two ways.

3

Records to be kept by a doctor providing maternity medical services shall contain such particulars, including particulars of the services rendered by the doctor, as may be determined by the Secretary of State after such consultation as is mentioned in sub-paragraph (2).

4

Where a doctor proposes to keep computerised records, he shall first obtain the written consent of the Health Board, unless records are also kept in terms of sub-paragraph (2)(a).

5

The Health Board shall consent to a doctor’s application to keep computerised records if it is satisfied that—

a

the computer system upon which he proposes to keep them has been accredited by the Secretary of State or another person on his behalf as satisfying the requirements contained in the Requirements for Accreditation for General Medical Practice Computer Systems in Scotland from time to time in force;

b

the security measures and the audit function incorporated into the computer system as accredited in accordance with paragraph (a) have been enabled; and

c

the doctor will comply with sub-paragraph (6),

and the Health Board may withdraw its consent if it ceases to be so satisfied.

6

Where a doctor keeps computerised records he shall comply with such guidelines and directions pertaining thereto as may be issued by the Secretary of State.

7

A doctor who keeps computerised records shall, as soon as possible following a request from the Health Board, allow the Health Board access to the information recorded on his computer system by means of the audit function referred to in sub-paragraph (5)(b).

8

A doctor shall send the records relating to a patient to the Health Board—

a

as soon as possible, at the request of the Health Board; or

b

where a person on his list dies, before the end of the period of 14 days beginning with the date on which he was informed by the Health Board of the death, or (in any other case) before the end of the period of 30 days beginning with the date on which he learned of the death.

9

To the extent that a patient’s records are computerised records, a doctor complies with sub-paragraph (8) if he sends to the Health Board a copy of those records—

a

in written form; or

b

with the written consent of the Health Board, in any other form.

10

The Health Board shall consent to the transmission of information other than in written form for the purposes of sub-paragraph (9)(b) if the doctor has specified—

a

how the record will be transmitted;

b

the format of the transmitted record;

c

how he will ensure that the record received by the Health Board is identical to that transmitted; and

d

how a written copy of the record can be produced by the Health Board,

and the Health Board is satisfied as to these matters; and the Health Board may withdraw its consent if it ceases to be so satisfied.

11

Where a doctor keeps computerised records he shall not disable, or attempt to disable, either the security measures or the audit function referred to in sub-paragraph (5)(b).