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PATIENT MEDICAL RECORDSAs of September 1999 the default Medical record is computerised Best Practice system; the older 6 x4 inch paper records are all re consultations pre 1999. The computer records should contain summaries of the important patient conditions prior to 1999. Patients new to the practice since 1999 have no paper files.CONFIDENTIALITYSee also Medical Records Patient paper based medical records/files are to be securely stored and not left in areas where unauthorised persons can have access to them. No information concerning a patient may be given out other than with the direct authority of a doctor and with the written consent of the patient. Computerised files are protected by a secure password system. Screensavers appear after 60 seconds. Patient's records should not be opened on a screen where another patient can view them. Computers are often used for patient education and it is a practice policy that on the whole patients see what is being written about them in a consultation. Therefore it is appropriate that patients can see computer screens in the consulting rooms. Patients new to the practice are to be informed that the practice normally allows access to patient records by other doctors in the practice, by locums and by general practice registrars attached to the practice and that patient information may be shared with other consulting health professionals where necessary. Patients have the right to limit access to their records. This will need to be recorded in their file. PATIENT ACCESS TO OWN MEDICAL RECORDSIt is practice policy that all patients have access to the health information contained in their file. See accessing your medical record. CONTENTEach patient is to have a separate medical record. The notes must not contain any derogatory comments or statements not supported by evidence. Patient medical records should contain: ¨ summary health history ¨ reason for attendance ¨ diagnosis ¨ management plans ¨ allergies and drugs to avoids ¨ significant family history ¨ known risks ¨ current medications ¨ all contacts (consultation, phone, home, out-of-hours visits etc) A copy of all significant referral letters as well as all reports from specialists, pathologists, and others, including action taken, should be kept in the file. There should be a note in the record of health interventions - health advice and leaflets, BP checks, pap smears etc. PATIENT-HELD RECORDSAs part of patient education, this practice provides patients with ‘patient-held’ records. These records help to promote better knowledge about prevention and illness, contribute to increased patient responsibility for their health by providing personalised information and promote both continuity and quality of care. Examples of patient-held records created in this practice include: ¨ diabetic diary ¨ asthma management plans ¨ child personal health record ¨ personal vaccination card STORAGEMedical records are not to be placed in view of any unauthorised person, or left in any public or semi-public areas of the practice. When not in use they are stored in the filing room. Computerised medical records should not be left open on the computer and the screensaver should be activated to come on after 60 seconds. If a patient is left in a room alone no other patients file is to be left open on Medical Director. INACTIVE PATIENT MEDICAL RECORDSBest Practice Files: When a patient dies or leaves the practice their file should marked as "Inactive" or "Deceased" using the selections in the Best Practice patient list. These files can later be retrieved by going to the Best Practice Patient Database, selecting "VIEW", and choosing either inactive or deceased patients. Deceased patients cannot be reactivated, but inactive ones can! Paper Files: Patients’ files are destroyed by shredding if: - 1. Patient over 25 years old and there has been no activity for 7 years 2. A child has reached 25 years of age i.e. 7 years after turned 18 and no activity during that 7 years. A file that has been inactive for two years is placed in secondary storage. Large patient files are separated into volumes and the previous volume placed in secondary storage. Deceased patient files are placed in separate secondary storage area and held for 7 years. Prepared: April 1999Reviewed: February 06, 2009
TRANSFERRING OF A PATIENT’S MEDICAL RECORDRELEASE AND TRANSFERPatients’ medical records or health summaries may only be transferred to, or accessed by, another party with the prior written consent of the patient. · The practice acknowledges the right of patients to transfer their care to another doctor in the same practice and/or in another practice. When a patient’s written consent is received the doctor concerned will decide whether a medical history summary with details of current medications and active problems or print out of the notes will be provided to their new doctor. There may be a cost for this. · The patient’s doctor also has the right to discontinue treatment of a patient. In these cases, the practice must help the patient find a new practitioner. · New patients to the practice may wish for their records to be transferred from their previous doctor. A standardised form is available to be filled in and signed by both patient and doctor or doctor’s representative. A record of this is kept in the patient file and a copy sent to the requested practitioner.
Prepared: April 1999Reviewed: 06-Feb-2009 | |||||||
