The Health and Personal Social Services (General Medical Services Contracts) Regulations (Northern Ireland) 2004

Patient records

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

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

(a) on forms supplied to him 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.

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

(4) The consent of the Board required by sub-paragraph (2)(b) shall not be withheld or withdrawn provided the Board is satisfied, and continues to be satisfied, that –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 Department or another person on its 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 head (a) have been enabled; and

(c) the contractor is aware of, and has signed an undertaking that he will have regard to–

(i) any guidelines issued by the Department and notified in writing to the contractor by the Board; and

(ii) any document amending any guidelines referred to in (i), which has been notified to the contractor by the Board,

concerning good practice in the keeping of electronic patient records.

(5) Where a patient’s records are computerised records, the contractor shall, 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 sub-paragraph (4)(b) to the extent necessary for the Board 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 Board –

(a) where a person on his list dies, before the end of the period of 14 days beginning with and including the date on which he was informed by the Board of the death, or (in any other case) before the end of the period of one month beginning with and including 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 Board.

(7) To the extent that a patient’s records are computerised records, the contractor complies with sub-paragraph (6) if he sends to the Board a copy of those records –

(a) in written form; or

(b) with the written consent of the Board in any other form.

(8) The consent of the Board 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 Board is identical to that transmitted; and

(d) how a written copy of the record can be produced by the Board.

(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 and version 1.2 (DTS/Nursing Prescribing) in August 2003. Copies are available on the NHS Information Authority’s website at www.nhsia.uk/sat/specification/pages. Copies may be obtained by writing to the NHS Information Authority, Systems Accreditation and Testing team, Aqueous 2, Aston Cross, Rocky Lane, Birmingham B6 5RQ