IT/Electronic Patient Records Policy
New contractual arrangements came into force on 1st April 2014 requiring GP practices to make available a statement of intent about the following IT developments:
- Referral Management Information
- Online Appointment Booking
- Online Booking of repeat prescriptions
- Summary Care Record
- GP2GP transfers of care records
- Patient Access to electronic records.
Please find below details of the arrangements we have in place for these developments at this Practice:
Referral Management Information
Practices must include the NHS Number as the primary identifier in all NHS clinical correspondence issued by the practice. All letters and information that we send to other organisations such as, hospitals, have an NHS number clearly shown.
Electronic Appointment Booking
We offer booking and cancelling of routine GP appointments online. Please register with the NHS app and follow the simple instructions to register.
Online Requesting of Repeat Prescriptions
Practices are required to promote and offer the facility for all patients, who wish to, to order online, view and print a list of their repeat prescriptions for necessary drugs, medicines or appliances. We currently offer the facility for ordering repeat prescriptions online. Please register either by selecting ‘Services’ followed by ‘GP Online services’ to find out what GP online services are available to you; alternatively, select ‘Prescriptions’ followed by ‘Emis GP online services’. Then simply follow the instructions to register.
Interoperable Records/Summary Care Record
Practices are required to upload changes to a patient’s summary information, at least daily, to the Summary Care record. Having your Summary Care Record available will help other doctors and nurses treating you away from your regular surgery, without your full medical record. They will have access to information about any medication you may be taking and any drugs to which you have a recorded allergy or sensitivity. More details about the Summary Care Record can be found on the Summary Care Record website. This function is already live; however, if you do not want your medical records to be available in this way please let us know. You can do this via the ‘opt out form’, available at reception.
GP2GP Transfers of Care Records
We are required to utilise the GP2GP facility for the transfer of patient records between practices, when a patient registers or de-registers. It is very important that you are registered with a doctor at all times. If you leave your GP and register with a new one, your medical records will be removed from your previous doctor and forwarded to your new GP via NHS England. It can take several weeks for paper records to reach the new surgery; with GP2GP, your electronic record is transferred to your new practice much sooner. GP2GP transfers are already activated at this practice for sending and receiving patient records.
Patient Access to Their Electronic GP Record
We are required to promote and offer the facility for patients to view online, export or print any summary of information from their records relating to medications, allergies, adverse reactions and any other additional details which have been agreed with the patient. This facility is already available to patients. Please register by selecting ‘Services’ followed by ‘Emis GP Online services’ to find out what GP online services are available to you. Once you register for Emis online services you may view your medication, allergies, adverse reactions and vaccinations.
Record amendments
Amending patient records: guidance for patients
Health and care organisations make every effort to keep your records accurate. However, occasionally information may need to be amended about you or your care.
If you think that the health or care information in your records is factually inaccurate, you have a legal right to ask for your records to be amended. For instance, you can ask for your home address to be changed because you moved house. You may also ask for something you feel has been inaccurately recorded, such as a diagnosis, to be corrected. However, it may not be possible to agree to your request.
You may need to provide evidence of the correct details, for example proof of address or change of surname after marriage. The organisation will then consider the request. Where organisations agree to make a change, they should make it as soon as practically possible, but in any event within one month.
Sometimes, you may disagree with information written in your record, but the information could still be factually correct. For example, you may disagree with a diagnosis you were given in the past. Whilst you can still ask the organisation to amend the entry that you feel is inaccurate, an organisation should not change it if the health and care professional believes it is factually correct or represents their professional opinion at the time of the assessment.. There are exceptions to this, for example, where there is a court order.
In cases where all parties agree that the information is inaccurate, it may still be necessary to retain the information. For example, health and care professionals may have taken the information into consideration when making decisions about treatment or care. This information would therefore be needed to justify and explain health and treatment decisions or to audit the quality of care received. You can, however, request for a comment or entry to be made in the record to show that you disagree with the content and what you think it should say.
If you are unhappy with the decision of a health or care organisation to retain information you wish to have deleted there are some steps you can take. In the first instance, you can make a formal complaint through that organisation’s complaints process. If you are unhappy with the outcome of that process then you might consider making a complaint to the Information Commissioner’s Office (ICO) or consider legal action.
To request for your record to be amended please email bobicb-ox.recordamendmentrequest@nhs.net
In the email please explain what information it is that you are querying, it is helpful to give details so we can understand the nature of your query, for example:
- The date/time of the consultation/record on your notes and who wrote it
- What specific aspect of the consultation/record you disagree with and why
We will not tolerate any abusive behaviour. Your correspondence may be uploaded to your records.
As you have now registered with Eynsham Medical Group, you will be granted prospective access to your GP records via the NHS app unless you opt out of this by informing the surgery.
Prospective access to full GP record includes the below details going forward from the date that you have registered with us. These details will not include any data that has been marked by the GP or the team as ‘Do not show in online record’.
- Medications
- Allergies/adverse reactions
- Demographics
- Immunisations
- Problems / diagnoses
- Consultations
- Test results (numeric values and normal range)
- Consent to share settings
- Free text (including text added to codes, results and consultations)
- Documents / letters and attachments
- Referrals
- Diary entries
It should be noted that patients will not be able to see any entries marked as 'Do not show in Online Record'. This may be the case for information that may contain third-party information, particularly sensitive information, or information that may be better disclosed directly for risk of potentially causing psychological harm. It is at the discretion of the relevant GP as to whether information may need to be concealed.
It is important to note that in some cases, information may not be concealed prior to the patient accessing their records if a clinician has not had the opportunity to review or conceal the particular investigation/document/consultation.
In some cases, there may be certain codes on an individual’s records or information that has been previously disclosed that may make them vulnerable to harm through online access to their notes (these may be safeguarding concerns or related to capacity concerns). Should new information come to light, access to the records could also be removed.
If you do not have access to your records and you have correctly signed up on the NHS app and proved your identity, this is likely to be the case – this can be reviewed should you provide a written request to the Practice.
If you disagree with what has been documented in the GP records on a factual basis, please see above for the protocol to request that this be reviewed.