The National Health Service (General Medical Services Contracts) Regulations 2004

Patient records

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

(2) The contractor shall keep adequate records of its attendance on and treatment of its patients and shall do so—

(a) on forms supplied to it for the purpose by the Primary Care Trust; or

(b) with the written consent of the Primary Care Trust, by way of computerised records,

or in a combination of those two ways.

(3) The contractor shall include in the records referred to in sub-paragraph (2) clinical reports sent in accordance with paragraph 7 of this Schedule or from any other health care professional who has provided clinical services to a person on its list of patients.

(4) The consent of the Primary Care Trust required by sub-paragraph (2)(b) shall not be withheld or withdrawn provided the Primary Care Trust is satisfied, and continues to be satisfied, that—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 another person on his behalf in accordance with “General Medical Practice Computer Systems—Requirements for Accreditation—RFA99” version 1.0, 1.1 or 1.2 (DTS/Nurse Prescribing)(1);

(b) the security measures, audit and system management functions incorporated into the computer system as accredited in accordance with 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 “Good Practice Guidelines for General Practice Electronic Patient Records” published on 26th September 2003(2).

(5) Where a patient’s records are computerised records, the contractor shall, as soon as possible following a request from the Primary Care Trust, allow the Trust to access the information recorded on the computer system on which those records are held by means of the audit function referred to in sub-paragraph (4)(b) to the extent necessary for the Trust to confirm that the audit function is enabled and functioning correctly.

(6) The contractor shall send the complete records relating to a patient to the Primary Care Trust—

(a) where a person on its list dies, before the end of the period of 14 days beginning with the date on which it was informed by the Primary Care Trust of the death, or (in any other case) before the end of the period of one month beginning with the date on which it learned of the death; or

(b) in any other case where the person is no longer registered with the contractor, as soon as possible at the request of the Primary Care Trust.

(7) To the extent that a patient’s records are computerised records, the contractor complies with sub-paragraph (6) if it sends to the Primary Care Trust a copy of those records—

(a) in written form; or

(b) with the written consent of the Primary Care Trust in any other form.

(8) The consent of the Primary Care Trust to the transmission of information other than in written form for the purposes of sub-paragraph (7)(b) shall not be withheld or withdrawn provided it is satisfied, and continues to be satisfied, with the following matters—

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

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

(c) how the contractor will ensure that the record received by the Primary Care Trust is identical to that transmitted; and

(d) how a written copy of the record can be produced by the Primary Care Trust.

(9) A contractor whose patient records are computerised records shall not disable, or attempt to disable, either the security measures or the audit and system management functions referred to in sub-paragraph (4)(b).

(1)

RFA99 is published by the NHS Information Authority. Version 1.0 was published in October 1999, version 1.1 in February 2001 and version 1.2 (DTS/Nurse Prescribing) in August 2003. Copies are available on the NHS Information Authority’s website at www.nhsia.nhs.uk/sat/specification/pages. Copies may also be obtained by writing to the NHS Information Authority, Systems Accreditation and Testing team, Aqueous 2, Aston Cross, Rocky Lane, Birmingham B6 5RQ.

(2)

This document is available on the Department of Health website at www.doh.gov.uk/pricare/computing or a copy can be obtained by writing to the Department of Health, PCIT Branch, Room 1N06, Quarry House, Quarry Hill, Leeds LS2 7UE.