The National Health Service (General Medical Services) Amendment (No. 4) Regulations 2000

Amendment of the 1992 Regulations

2.—(a) In Schedule 2 to the 1992 Regulations (terms of service), for paragraph 36 there shall be substituted the following paragraph—

“Records

36.— (1) In this paragraph, “computerised records,” means records created by way of entries on a computer.

(2) A doctor shall keep adequate records of the illnesses and treatment of his patients, and shall do so—

(a) on forms supplied to him for the purpose by the Health Authority; or

(b) subject to sub-paragraphs (3) and (4), by way of computerised records,

or in a combination of those two ways.

(3) Where a doctor proposes to keep computerised records, he shall first obtain the written consent of the Health Authority.

(4) The Health Authority 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 in accordance with “General Medical Practice Computer Systems—Requirements for Accreditation—RFA99”(1);

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

(c) the doctor is aware of, and has signed an undertaking, that he will have regard to the guidelines contained in “Good Practice Guidelines for General Practice Electronic Patient Records”(2),

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

(5) Where a doctor keeps computerised records he shall, as soon as possible following a request from the Health Authority, allow the Health Authority access to the information recorded on his computer system by means of the audit function referred to in paragraph (4)(b).

(6) A doctor shall send the records relating to a patient to the Health Authority—

(a) as soon as possible, at the request of the Health Authority; 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 Authority of the death, or (in any other case) before the end of the period of one month beginning with the date on which he learned of the death.

(7) To the extent that a patient’s records are computerised records, a doctor complies with sub-paragraph (6) if he sends to the Health Authority a copy of those records—

(a) in written form; or

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

(8) The Health Authority shall consent to the transmission of information other than in written form for the purposes of paragraph (7)(b) if it is satisfied with the following matter—

(a) the doctor’s proposals as to how the record will be transmitted;

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

(c) how the doctor will ensure that the record received by the Health Authority is identical to that transmitted; and

(d) how a written copy of the record can be produced by the Health Authority,

and the Health Authority may withdraw its consent if it ceases to be satisfied as to any of the above matters.

(9) 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 paragraph (4)(b).”.

(1)

This was published by the National Health Service Information Authority in October 1999. Copies may be obtained by writing to the National Health Service Information Authority, 15 Frederick Road, Birmingham B15 1JD.

(2)

These guidelines were published by the National Health Service Executive on 31st August 2000. Copies may be obtained by writing to PC-GPMS, Room 7E24. Quarry House, Quarry Hill, Leeds LS2 7UE.