The National Health Service (General Medical Services Contracts) Regulations 2015

Patient records

67.—(1) The contractor must keep adequate records of its attendance on and treatment of its patients and must do so—

(a) on forms supplied to it for the purpose by the Board; or

(b) with the written consent of the Board, by way of computerised records,

or in a combination of those two ways.

(2) The contractor must include in the records referred to in paragraph (1), clinical reports sent in accordance with paragraph 12 of Schedule 3 or from any other health care professional who has provided clinical services to a person on the contractor’s list of patients.

(3) The consent of the Board required by paragraph (1)(b) may not be withheld or withdrawn provided the Board is satisfied, and continues to be satisfied, that—

(a) the computer system upon which the contractor proposes to keep the records has been accredited by the Secretary of State or by another person acting on the Secretary of State’s behalf in accordance with “General Practice Systems of Choice Level 2”(1);

(b) the security measures, audit and system management functions incorporated into the computer system as accredited in accordance with sub-paragraph (a) have been enabled; and

(c) the contractor is aware of, and has signed an undertaking that it will have regard to, the guidelines contained in “The Good Practice Guidelines for GP electronic patient records” (Version 4) published on 21st March 2011(2).

(4) Where the patient’s records are computerised records, the contractor must, as soon as possible following a request from the Board, allow the Board to access the information recorded on the computer system on which those records are held by means of the audit function referred to in paragraph (3)(b) to the extent necessary for the Board to confirm that the audit function is enabled and functioning correctly.

(5) The contractor must send the complete records relating to a patient to the Board—

(a) where a person on the contractor’s list of patients dies, before the end of the period of 14 days beginning with the date on which the contractor was informed by the Board of that person’s death, or (in any other case) before the end of the period of one month beginning with the date on which the contractor learned of that person’s death; or

(b) in any other case where the person is no longer registered with the contractor, as soon as possible at the request of the Board.

(6) To the extent that a patient’s records are computerised records, the contractor complies with paragraph (5) if it sends to the Board a copy of those records—

(a) in writing; or

(b) with the written consent of the Board, in any other form.

(7) The consent of the Board to the transmission of information other than in writing for the purposes of paragraph (6)(b) may not be withheld or withdrawn provided it is satisfied, and continues to be satisfied, with the following matters—

(a) the contractor’s proposals as to how the record is to be transmitted;

(b) the contractor’s proposals as to the format of the transmitted record;

(c) the manner in which the contractor proposes to ensure that the record received by the Board is identical to that transmitted; and

(d) the manner in which a written copy of the record may be produced by the Board.

(8) A contractor whose patient records are computerised records must not disable, or attempt to disable, either the security measures or the audit system management functions referred to in paragraph (3).

(9) In this regulation, “computerised records” means records created by way of entries on a computer.

(1)

GP Systems of Choice is a scheme by which the National Health Service funds the cost of GP clinical IT systems in England. Guidance about this scheme is available from the Health and Social Care Information Centre, 1 Trevelyan Square, Boar Lane, Leeds, LS1 6AE.

(2)

This guidance is available at http://www.gov.uk/government/publications/the-good-practice-guidelines-for-gp-electronic-patient-records-version-4-2011. Hard copies are available from the Department of Health, Richmond House, 79 Whitehall, London SW1A 2NS.