PART 10Records and information
Patient records67
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The consent of the Board required by paragraph (1)(b) may not be withheld or withdrawn provided the Board is satisfied, and continues to be satisfied, that—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”M1;
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 M2.
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.
F15
Where a patient on the contractor’s list of patients dies, the contractor must send the complete records relating to that patient to the Board—
a
in a case where the contractor was informed by the 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 one month beginning with the date on which the contractor learned of that patient’s death.
5A
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 send to the Board—
a
the complete records, or any part of the records, sent via the GP2GP facility in accordance with regulation 69 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.
5B
Where a patient on a contractor’s list of patients—
a
is removed from that list at that patient’s request under paragraph 23 of Schedule 3, or by reason of the application of any of paragraphs 24 to 31 of that Schedule; 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 Board.
5C
Where a contractor’s responsibility for a patient terminates in accordance with paragraph 32 of Schedule 3, 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 Board.
5D
For the purposes of this regulation, “GP2GP facility” has the same meaning as in paragraph (2) of regulation 69.
F26
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F37
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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.