Practices can download the guidance here. This is an interactive guide, but the key points are summarised below.
What does the contract say?
Under the five-year GP contract agreed in 2019, NHS England and the BMA agreed a number of digital changes that would become contractual requirements. See here for full details.
This latest guidance specifically relates to giving patients online access to their full record. Under the contract the BMA and NHS England have agreed that all patients will have online access to their full record, including the ability to add their own information, as the default position from April 2020. New patient registrants at the practice should be provided with full online access to prospective data from April 2019, subject to existing safeguards for vulnerable groups, third party confidentiality and system functionality.
What do practices need to do now?
As of April, new patients should be offered full online access to their patient record, for prospective information (this means information starting from their date of registration with the practice. As well as the coded record, which is already available, this should include access to free text consultation notes and documents, including hospital letters and referral letters.
How do practices need to do this?
Patient safety and safeguarding is key when providing full access to the patient record. The guidance says:
- When recording third party information, and if it is unknown to the patient, GP practices will need to ensure that this information becomes redacted from patient view.
- Practices should also ensure that information is recorded in a way which makes it easy for
the patients to understand it.
- Before record access is switched on all the data (detailed coded or full record access) that the patient will see should be checked for sensitive data that needs to be redacted. It is helpful to establish a practice record keeping policy about recording and redacting new entries of potentially harmful and confidential third party data even if they do not currently have online record access. There is more advice on redacting information here. The guidance linked to above shows how to redact information in each clinical system.
- Practices will need to enable full record access within their clinical system’s organisational settings where the functionality exists. The guidance linked to above shows how to do this in each clinical system.
- The records only need to show information recorded from the date that the patient registered at the practice. This can be set within the organisational settings or for individual patients
- Practices should not enable record access for individual patients if there are any safeguarding/safety concerns.
Useful resources on Medeconomics
- Online access to patient records - a checklist
- Redacting information from medical records - medico-legal advice
- Proxy access to online records