Guidance

1.  Medical Records – Adopted Children

Under adoption legislation, an adopted child is given a new NHS number, and all previous medical information relating to that child is put into a newly created health record. Any information relating to the identity or whereabouts of the birth parents should not be included in the new record. The change of name, NHS number and transfer of previous health information into a new health record should take place for both GP records and hospital records. There should not then be any difficulty in obtaining information about the child’s previous treatment in secondary care.

Whilst changing or omitting information from medical records would usually be contrary to ethical and professional guidance this is not the case for the records of adopted children as there is a legal requirement that it takes place.

The pre-adoptive information should be regarded as confidential and the practice must ensure that robust systems are in place for access or disclosure. Different clinical systems have employed different solutions and if you are unsure of what is in place in your clinical system then you should speak to your clinical supplier regarding this situation. By logging a call to their helpdesk you will establish an audit trail which confirms how the scanned records containing ‘old details’ are managed by them.

We have updated and amended a previously shared suggested practice protocol for dealing with a patient who undergoes adoption that you may wish use and adapt for your practice processes.

PCSE now deal with the movement of adoption records on behalf of NHSE.

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2.  Medical Records – Alterations

We are often asked under what circumstances, and how medical records may be altered.  This article condenses advice from the Medical Defence Organisations and the GMC:

  • Medical notes must never be overwritten or inked out, and computer records should not be completely deleted.
  • Hard copy errors should be scored out with a single line, so that the original writing is still visible, and the correct entry should be written alongside, with the time and date and your signature.
  • Any additions should be separately dated, timed and signed.
  • If making an entry or correction to a computer record, ensure there is an audit trail identifying the date and time of the change and the person who made it.
  • It should be immediately obvious that an amendment has been made.
  • QOF codes form part of the record so need to be an accurate description of the patient’s condition or treatment.
  • If you discover a factual error, you should inform the patient and explain any implications for their health or treatment. Apologise and explain that the records will be amended. You may wish to add a note that you have explained the error to the patient.
  • Occasionally, there may be circumstances, after a full risk assessment, that it may be agreed that information will be removed from a paper record.  This should be discussed with the patient and guidance sought from your Caldicott Guardian and/or MDO before making a decision.
  • If you do not agree with a request for an amendment, you can explain to the patient that they may add a statement that they disagree with some part of the content.  If the patient is still unhappy, they may follow the normal complaints procedure or approach the Information Commissioner’s Office.

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3.  Medical Records – Handling and Retention

A brief summary of the more detailed advice is available here which includes advice about how long medical records should be kept.

For definitive advice please click here: Medical Records Code of Practice 2021

GMC Good Medical Practice requires that:

‘you keep clear, accurate and legible records, reporting the relevant clinical findings, the decisions made, the information given to patients, and any drugs prescribed or other investigation or treatment.’  It also stipulates that you ‘make records at the same time as the events you are recording or as soon as possible afterward.’

All of the following should be part of the record forwarded when the patient is de-registered;

  • records of consultations.
  • letters.
  • medical reports.
  • other clinical information.

They should not normally include:

  • solicitor’s letters.
  • documentation pertaining to complaints procedures.
  • PMAs.
  • Social Services reports (unless you believe this is necessary for the active and current treatment of the patient).
3.1  Can I shred paper records once they have been scanned?

Technically, if they are kept in an electronic format, that cannot be altered i.e. scanned document, then they can be deemed to provide a true and accurate record and it is probably safe to destroy paper records.  However, you must comply fully with the Good Practice Guidelines for Electronic Patient Records (version 5).    You should also remember that where any records relate to p known medico-legal issues, (complaints, civil or criminal law) practices should keep all relevant records pending further advice from their medical defence organisation.

When summarising and shredding you should ensure that you:

  • identify each file or document to be destroyed;
  • record that the complete file or document has been stored electronically;
  • have ensured that the electronic version is a true and accurate copy of the original, or state how it is different.

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3.2  Access to Health Records by Diagnostic Staff

This helpful document provides guidance for patients and Healthcare professionals and summarises guidance already available.  This is with regard to clinicians accessing medical information without direct consent, such as a radiologist wanting to view the history to help interpret a CXR or a clinical biochemist wanting to look at the medication list when interpreting results.

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4.  Online Access to Medical Records

4.1  Accelerating Patient Access to their GP Held Records

From April 2020 there was a contractual requirement for practices to offer all patients online access to all prospective data on their patient record unless exceptional circumstances apply. (Additionally, patients can also ask for their full retrospective medical record, this will require sensitivity and third-party data checking)

There have been a number of dates given for the roll out of this programme only to be suspended.

On 29th November 2022 the BMA reached a negotiated agreement with NHS England and DHSC over halting the mass roll out of the records access programme, for those practices who wish to delay the process.

Following proposed changes to the 2023/2024 GP contract which were announced in April 2023, legislation has now been passed so that new health information will be available to all patients (unless they have individually decided to opt-out or any exceptions apply) by 31 October 2023 at the latest.

The BMA have published a document of some useful FAQs on the current programme that you may have, depending upon what your practice has or has not yet put in place.

If your practice has yet to switch on access, NHS Digital’s GP readiness checklist will support you with carrying out all the essential actions required for launching online record access safely and effectively.

Further Guidance

For those practices preparing to proceed, the BMA also have guidance and we would suggest practices might like to use the General Practice Readiness Checklist which is accessible on the FutureNHS platform.

There is a channel on the FutureNHS website dedicated to Accelerating Citizen Access with a wealth of documents and resources that you may find useful.

NHS Digital also have a dedicated webpage with a number of resources including The RCGP GP Online Toolkit .

Going Live with Online Access to Medical Records

Lisa Harding, Director of Primary Care, talks with Matt Perkins, Business Manager at the Coastal Medical Partnership and Wessex LMCs PM Supporter, about his practice’s experience of going live with online access to medical records.  In particular, Matt describes how they approached:

  • preparations to go live;
  • communications with patients;
  • staff training and awareness raising;
  • reviewing vulnerable patients’ access;
  • managing the workload.

For more guidance on online access, go to NHS Digital

Listen to the podcast here

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4.2  Accelerated Access to GP held Patient Records – A Summary for the Admin Team

Lisa Harding, Director of Primary Care at Wessex LMCs, talks with Caroline Sims, Information Governance Consultant and Data Protection Officer in the Hampshire & IOW area.

Listen to the podcast here

Caroline explains:

  • What accelerated access to GP held patient records is
  • What is meant by prospective access
  • What patients will be able to see
  • Which patients will have online access
  • How proxy access will work
  • How patients can access their record
  • If patients can see redacted information
  • If patients will be able to see who has accessed and made an entry on their record

Further Reading: NHS Digital: https://digital.nhs.uk/services/nhs-app

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4.3  104 and 106 Codes

There has been much confusion about what Snomed CT codes can or should be used and what effect they have on the online access if you do. NHSE&I have produced a handy guide that documents these scenarios and this can be downloaded from the FutureNHS website.

Update – system changes for all practices using TPP and EMIS

General practices were previously informed that from April there will be system changes for all practices using TPP and EMIS systems to provide all patients with easy access to their future health records. Go-live date is now expected to be 1st November 2023.

For more information please click HERE

There are a number of resources that NHSE&I have published on FutureNHS. This includes a useful FAQ document. We would recommend subscribing to this channel, it is quick and easy to sign up.

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4.4  Proxy Access

This a topic referred to and the FAQs say that the new changes do not apply to proxy.

The accelerated access program is for those aged 16yrs+. However, we would recommend that this topic is reviewed and details can be found at:

RCGP https://elearning.rcgp.org.uk/mod/book/view.php?id=13455&chapterid=770

NHSD https://digital.nhs.uk/services/nhs-app/nhs-app-guidance-for-gp-practices/guidance-on-nhs-app-features/linked-profiles-and-proxy-access

In the meantime:

  • Remember they are the data controller.
  • Remember the patient will be able to immediately see any entry that is not redacted from online view.
  • The “switch on” of the online access only relates to the GP record (not community modules, for example).
  • Ensure all staff and clinicians are fully aware of the importance of what they write in the record and how to “redact” from online view anything that is sensitive and or safeguarding relevant.
  • Be aware that all the following will be visible
    • Consultations with full text – unless hidden at the time of entry
    • Results- once filed in record
    • Codes
    • Documents – once filed in record
    • Appointment Information
  • Access to retrospective (historic) records can still be requested by patients.
  • If documents are filed into the record, they will be visible to online view.
  • Ensure all staff processing documents know how to redact from online view until the document has been reviewed for suitability.
  • There is a code that can be added to a record that will hold back online access “Enhanced review indicated before granting access to own health records – Snomed code 1364731000000104. We understand that this code must be added prior to the launch date of 1st November 2022. However there has been confusion about the use of this code, see the section above entitled 104 & 106 codes.
  • Possible uses may include but not limited to
    • Patients that lack capacity
    • Patients with safeguarding protections or concerns in place
    • Patients in domestic abuse situations

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4.5  What can you do and what is available?

In preparation, there are a number of resources and options that practices may wish to consider.

BMA

The BMA guidance includes:-

  • redaction – how and what to consider
  • clinical safety concerns
  • the legal background
  • summary of options.
  • template letter for sending to system suppliers

NHSE & RCGP

FuturesNHS – GP Online Services Channel

There is a wealth of material, including webinar recordings and slides. we recommend signing up to this channel, it is quick and easy and includes a useful discussion forum for any queries you may have. There are also a number of documents and FAQs .

All staff, including locums, should receive the necessary training with regards to checking and entering information into patient records and familiarise themselves with any change in business processes and GP system functionality. Access to training materials and webinar recordings can be found here.

NHS Digital

We also have a number of webpages that deal with other medical records issues: –

We also have a number of training resources related to these topics. Please refer to Wessex LMCs Education, Education & Events

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4.6  Clinical System Guides

Wessex LMCs – An EMIS guide for redacting a consultation

Wessex LMCs – A TPP guide for redacting a consultation (Please note that due to the configuration of your system you may not have all 3 processes available to you)

Consider using a test patient in your clinical system and similarly a test patient in the NHS App to see how actions within your clinical system will look to the patient within the App. NHS Digital have full details of how to do this. The NHS App test patient can be set up on a computer or laptop, as well as a smartphone, android or tablet.

With our kind thanks to Dr Michelle Sharma from BSW who has produced   a crib sheet or all healthcare professionals that shows how to “Redact from online view”.

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4.7  NHS App Access to GP Health Records – Patient Communications for Practices

NHS Digital have produced some materials you can use to inform patients about having access to their GP health records.

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4.8  Further Reading

Information Governance Lunch and Learn

Subject Access Requests & Dealing with Third Party Data recording

Data Sharing Update from Caroline Sims at the PM Conference, June 2022

Information Governance with Adam Horton-Tuckett – from PM Webinar 25 May 2022

NHS Acronyms and Abbreviations:

Guide to Document Workflow for Patient Visibility – a useful flowchart for how workflow may be managed for patient visibility. With our thanks to the author, Dr Devin Gray, Clinical Lead for Digital First (Wandsworth) who has kindly offered it’s free use.

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5.  Parental Responsibility, Access to Children’s Medical Records and Parental Disputes.

5.1  Basic Principles
  • Parental responsibility refers to the rights, duties, powers and responsibilities that most parents have in respect of their children.
  • Parental responsibility includes the right of parents to consent to treatment on behalf of their children, provided the treatment is in the interests of the child.
  • Those with parental responsibility have a statutory right to apply for access to their children’s health records, although if the child is capable of giving consent, he or she must consent to the access
  • Competent children can decide many aspects of their care for themselves.
  • Where doctors believe that parental decisions are not in the best interests of the child, it may be necessary to seek a view from the courts, whilst meanwhile only providing emergency treatment that is essential to preserve life or prevent serious deterioration.
  • Parental responsibility is afforded not only to parents, however, and not all parents have parental responsibility, despite arguably having equal moral rights to make decisions for their children where they have been equally involved in their care.

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5.2  Who Possesses Parental Responsibility?

The law in relation to parental responsibility has recently been revised. For a child whose birth was registered from 15th April 2002 in Northern Ireland, 1st December 2003 in England and Wales and 4th May 2006 in Scotland, both of the child’s parents have parental responsibility if they are registered on the child’s birth certificate.

Throughout the United Kingdom, a mother automatically acquires parental responsibility at birth. However, the acquisition of parental responsibility by a father varies according to where and when the child’s birth was registered:

  • For births registered in England, Wales or Northern Ireland

A father acquires parental responsibility if he is married to the mother at the time of the child’s birth or subsequently. An unmarried father will acquire parental responsibility if he is recorded on the child’s birth certificate (at registration or upon re-registration) from 1st December 2003 in England or Wales and from 15th April 2002 in Northern Ireland.

  • For births registered in Scotland

A father acquires parental responsibility if he is married to the mother at the time of the child’s conception or subsequently. An unmarried father will acquire parental responsibility if he is recorded on the child’s birth certificate (at registration or upon re-registration) from 4th May 2006.

  • For births registered outside the United Kingdom? The above rules for the UK country where the child resides apply.

An unmarried father, whose child’s birth was registered before the dates mentioned above, or afterwards if he is not recorded on the child’s birth certificate, does not have parental responsibility even if he has lived with the mother for a long time. However, the father can acquire parental responsibility by way of a court registered parental responsibility agreement with the mother or by obtaining a parental responsibility order or a residence order from the courts. Married step-parents and registered civil partners can acquire parental responsibility in the same ways. Parental responsibility awarded by a court can only be removed by a court.

Parents do not lose parental responsibility if they divorce – neither can a separated or divorced parent relinquish parental responsibility. This is true even if the parent without custody does not have contact with the child and does not make any financial contribution.

Other people can also acquire parental responsibility for a child. A testamentary guardian will acquire parental responsibility if no one with parental responsibility survives the testator. A guardian appointed by a court will also acquire parental responsibility. When a child is adopted, the adoptive parents are the child’s legal parents and automatically acquire parental responsibility. A local authority acquires parental responsibility (shared with anyone else with parental responsibility) while the child is subject to a care or supervision order. Foster parents rarely have parental responsibility. For a child born under a surrogacy arrangement, parental responsibility will lie with the surrogate mother (and husband if married) until the intended parents either (a) obtain a parental order from a court under the Human Fertilisation and Embryology Act 1990 or (b) adopt the child.

In England, Wales and Northern Ireland, parental responsibilities may be exercised until a young person reaches 18 years. In Scotland, only the aspect of parental responsibilities concerned with the giving of “guidance”1 endures until 18 years, guidance meaning the provision of advice. The rest is lost when the young person reaches 16 years.

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5.3  Parental Disputes

Disputes between parents can be difficult for everybody involved in the child’s care. Health professionals must take care to concern themselves only with the welfare of the child and to avoid being drawn into extraneous matters such as marital disputes. Discussion aimed at reaching consensus should be attempted.

The legal definition of a child is 0 to 18 years of age; however young people may be able to make independent decisions from as young as 12, depending on the circumstances. Section 11 of the Children Act 2004 places a statutory duty on the NHS to safeguard and promote the welfare of children. The Victoria Climbie Enquiry Report 2003 (9.104) stresses the importance of GP registration for every child. It sets out the importance of knowing the identity of those registering the child and their relationship to that child.

Where parents are separated and one of them applies for access to the medical record, doctors are under no obligation to inform the other parent, although they may consider doing so if they believe it to be in the child’s best interests. Parents have equal responsibility irrespective of whether the child lives with them unless there is clear guidance from the courts to the contrary.

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5.4  What if Parents Disagree on Which Address to use for Registration?

You should encourage the parents to discuss the issue between themselves try to reach a consensus. Depending on the age of the children but you may wish to consider if they are competent to contribute to any decisions relating to their registration.

From a practical point of view it makes sense for the primary address registered to be that at which the children spend most of their time. This makes it easier for the practice and other healthcare professionals to contact the child/parent should an urgent matter arise. It may be possible to record a secondary address and contact details in the notes, highlighting that the child spends some part of the week residing at this alternative address.

Obviously if either parents address is outside of your practice boundary you could use this as a reason for not using that address.

Another question you may like to ask is who is most likely to be bringing the child to the surgery or take them to outpatient appointments etc?

Parents wishing to access children’s medical records

We are often asked for advice about the treatment of children and young people and the disclosure to parents of sensitive data relating to children and young people. Young people may fear seeking medical help if they do not trust that consultations will be confidential. Parents may become angry if they do not understand the GP’s legal and professional duties relating to the treatment and confidentiality.

See also GMC 0-18 years

BMA Guidance on the subject states quite clearly that ‘Both of a child’s legal parents have parental responsibility if they were married at the time of the child’s conception or at some time thereafter.

BMA Ethical Guidance on Parental Responsibility

It is important to remember that even quite young children may be ‘Gillick competent’ see Confidentiality – Children and therefore may have legal capacity to consent or dissent to disclosure of their confidential medical records. In addition, you must always take into account your legal and professional obligation to act at all times in the child’s best interests.

Sharing information with separated parents

In a contentious divorce situation it would be worth checking with your medical defence organisation if there is any doubt about the wisdom of providing access to the medical records.

Acquired parental responsibility

* An unmarried father can acquire parental responsibility by;

  • applying for and getting a Residence order
  • applying to the court for a Parental Responsibility order
  • making a parental responsibility agreement (in a set procedure) with the mother
  • being appointed the child’s guardian (once the appointment takes effect)
  • subsequently marrying the mother of the child.

Step-parents do not acquire parental responsibility on marriage, but they do have a responsibility to safeguard the welfare of any step-children in their care, and are responsible for the maintenance of a step-child where a marriage means the step-child is a “child of the family.” (i.e., a child who has been treated as a member of the family.

step-parent may acquire parental responsibility by:

  • obtaining a Residence order
  • adopting the child.

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