The National Health Service (General Medical Services Contracts) (Wales) Regulations 2023

Patient records

78.—(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 Local Health Board, or

(b) with the written consent of the Local Health 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 sub-paragraph (1) clinical reports sent in accordance with paragraph 10 or from any other health care professional who has provided clinical services to a person on its list of patients.

(3) The consent of the Local Health Board required by sub-paragraph (1)(b) must not be withheld or withdrawn provided the Local Health Board is satisfied, and continues to be satisfied, that—

(a) the GP digital services upon which the contractor proposes to keep the records meet the requirements set out in the National Framework Agreement for GP Clinical Systems and Services in Wales,

(b) the security measures, audit and system management functions incorporated into the GP digital services are compliant with the National Framework Agreement for GP Clinical Systems and Services in Wales have been enabled, and

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

(4) Where the contractor’s patient records are computerised records, the contractor must, as soon as possible following a request from the Local Health Board, allow the Local Health 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 sub-paragraph (3)(b) to the extent necessary for the Local Health Board to confirm that the audit function is enabled and functioning correctly.

(5) Where a patient on the contractor’s list of patients dies, the contractor must send the complete records relating to that patient to the Local Health Board—

(a) in a case where the contractor was informed by the Local Health Board of that patient’s death, before the end of the period of 14 days beginning with the date on which the contractor was so informed, or

(b) in any other case, before the end of the period of 4 weeks beginning with the date on which the contractor learned of that patient’s death.

(6) Where a patient on a contractor’s list of patients has registered with another provider of primary medical services and the contractor receives a request from that provider for the complete records relating to that patient, the contractor must, as soon as possible and in any event before the end of the period of 28 days beginning with the day on which it receives the request from the provider, send to that provider the complete records (other than any part held only in paper form), via the GP2GP facility in accordance with paragraph 80 and send to the Local Health Board—

(a) the complete records, or any part of the records, sent via the GP2GP facility in accordance with paragraph 80 for which the contractor does not receive confirmation of safe and effective transfer via that facility, and

(b) any part of the records held by the contractor only in paper form.

(7) Where a patient on a contractor’s list of patients—

(a) is removed from that list at that patient’s request under paragraph 28, or by reason of the application of any of paragraphs 29 to 36, and

(b) the contractor has not received a request from another provider of medical services with which that patient has registered for the transfer of the complete records relating to that patient,

the contractor must send a copy of those records to the Local Health Board.

(8) Where a contractor’s responsibility for a patient terminates in accordance with paragraph 37, the contractor must send any records relating to that patient that it holds to—

(a) if known, the provider of primary medical services with which that patient is registered, or

(b) in all other cases, the Local Health Board.

(9) For the purposes of this regulation, “GP2GP facility” has the same meaning as in sub-paragraph (2) of paragraph 80.

(10) To the extent that a patient’s records are computerised records, the contractor complies with sub-paragraphs (5), (7) or (8) if it sends to the Local Health Board a copy of those records—

(a) in written form, or

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

(11) The consent of the Local Health Board to the transmission of information other than in written form for the purposes of sub-paragraph (10)(b) must 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) how the contractor is to ensure that the record received by the Local Health Board is identical to that transmitted, and

(d) how a written copy of the record can be produced by the Local Health Board.

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

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