The Good Practice Guidelines for GP electronic patient records Version 4 (2011)

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The Good Practice Guidelines for GP electronic patient records v4 (2011)

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The Good Practice Guidelines for GP electronic patient records v4 (2011)

LS2 7UE0113 397 4468

Lesley CookeDH Informatics1N24 Quarry HouseLeeds

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.

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Department of Health (DH)/Royal College of General Practitioners (RCGP)/British Medical Association (BMA)

21 Mar 2011GPs

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GPG v3.1 [Gateway 5098] GPG v3.1.003 [supplement to GPG v3.1]

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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 5Shared 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

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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 8b.7 GP2