The Good Practice Guidelines for GP electronic patient records Version 4 (2011) 1 The Good Practice Guidelines for GP electronic patient records v4 (2011) DH INFORMATION READER BOX Policy Estates HR / Workforce Commissioning Management IM & T Planning / Finance Clinical Social Care / Partnership Working Document Purpose Best Practice Guidance Gateway Reference 15787 Title The Good Practice Guidelines for GP electronic patient records v4 (2011) Department of Health (DH)/Royal College of General Practitioners Author (RCGP)/British Medical Association (BMA) Publication Date 21 Mar 2011 Target Audience GPs Circulation List #VALUE! Description The Good Practice Guidelines for GP electronic patient records v4 will act as a reference source of information for all those involved in developing, deploying and using general practice IT systems. Cross Ref 0 Superseded Docs GPG v3.1 [Gateway 5098] GPG v3.1.003 [supplement to GPG v3.1] Action Required N/A Timing N/A Contact Details Lesley Cooke DH Informatics 1N24 Quarry House Leeds LS2 7UE 0113 397 4468 0 For Recipient's Use 2 The Good Practice Guidelines for GP electronic patient records v4 (2011) Contents Contents ....................................................................................................................................2 Foreward....................................................................................................................................6 Executive summary ...................................................................................................................8 Chapter 1 - Strategic context for the Good Practice Guidelines for GP electronic patient records v4 (2011).....................................................................................................................10 1.1 Introduction ..............................................................................................................10 1.2 Background..............................................................................................................10 1.3 GPGv4 scope and definition ....................................................................................11 1.4 GPGv4 Content........................................................................................................11 Chapter 2 - The Purposes of Health Records..........................................................................13 2.1 Clinical purposes......................................................................................................13 2.2 Non-clinical purposes...............................................................................................13 2.3 Additional purposes .................................................................................................14 2.4 Emerging purposes..................................................................................................14 Chapter 3 – Clinical Safety Assurance ....................................................................................16 3.1 Introduction ..............................................................................................................16 3.2 Clinical safety approach...........................................................................................16 3.3 Clinical safety assurance and inter-operability.........................................................17 3.4 Current NHS safety standards for IT systems (DSCN 14/2009 & 18/2009).............18 3.5 Future Safety Standards including changes to the Medical Device Directive..........19 3.6 Key clinical safety summary points ..........................................................................20 Chapter 4 - Records Governance............................................................................................21 4.1 Information governance framework .........................................................................21 4.2 Legal aspects...........................................................................................................23 4.3 Standards.................................................................................................................31 4.4 Other relevant publications ......................................................................................32 4.5 Governance issues particular to shared electronic patient records .........................33 4.6 Records and record keeping – guidance from health professional bodies ..............35 4.7 Consent....................................................................................................................37 4.8 Information governance and data disclosure ...........................................................38 4.9 Retention of GP electronic patient records and associated audit trails when a patient is no longer registered with a practice.....................................................................47 4.10 The Information Governance Toolkit, & Information Governance Statement of Compliance (IGSoC) ...............................................................................................51 Chapter 5–Shared electronic patient records ..........................................................................52 5.1 Introduction ..............................................................................................................52 5.2 Shared electronic patient records – background .....................................................52 5.3 Sharing records with patients (Record Access) .......................................................59 Chapter 6 - High Quality Patient Records................................................................................64 6.1 Introduction ..............................................................................................................64 6.2 Information quality and modern general practice.....................................................65 6.3 Capturing information in the consultation.................................................................66 6.4 Capturing information from outside the practice ......................................................71 6.5 Recognising high quality patient records .................................................................74 6.6 System specific issues.............................................................................................77 6.7 Data quality and shared records ..............................................................................79 6.8 Conclusion ...............................................................................................................81 Chapter 7 - Clinical Coding Schemes......................................................................................82 7.1 Coding schemes in current use ...............................................................................82 7.2 Future standardisation of coding schemes across health care SNOMED-CT .........83 7.3 Features of Read Codes..........................................................................................83 3 The Good Practice Guidelines for GP electronic patient records v4 (2011) 7.4 General issues relating to terminology use..............................................................92 7.5 Sharing coded information .......................................................................................97 7.6 Preparing to move to SNOMED-CT, what to expect................................................99 7.7 The International Classification for Primary Care (ICPC).......................................101 Chapter 8 - Data Transfer and Inter-operability.....................................................................102 8.1 Introduction ............................................................................................................102 8.2 Clinical safety assurance .......................................................................................102 8.3 Chapter organization..............................................................................................102 Chapter 8a - The Personal Demographics Service (PDS) ....................................................103 8a.1 Introduction ............................................................................................................103 8a.2 Access & security...................................................................................................103 8a.3 PDS tracing............................................................................................................104 8a.4 The NHS Number (England & Wales) ...................................................................105 8a.5 Data quality ............................................................................................................106 Chapter 8b - GP2GP Electronic Record Transfer..................................................................108 8b.1 The rationale for electronic GP2GP record transfer...............................................108 8b.2 The nature of electronic GP2GP record transfer ...................................................109 8b.3 The limitations of electronic GP2GP record transfer..............................................110 8b.4 General clinical safety............................................................................................117 8b.5 Electronic and paper GP2GP record transfer ........................................................117 8b.6 GP electronic record quality...................................................................................118