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Legal warning to conform to new records guidance

GPs using electronic patient records could put themselves at risk of legal action unless they follow extensive new guidance on the issue, med-icolegal experts have advised.

The guidance, released by Joint Computing Group of the GPC and the RCGP,

covers the implications for GPs of new legislation on data protection, human rights and computer misuse, as well good practice for the new contract.

It contains advice on migrating towards paperless re-cords, getting patient consent for extracting clinical data, the purpose of getting the data and how long records must be kept.

Dr Matthew Lee, medico-legal adviser at the Medical Defence Union, said the guidelines would be regarded as the 'gold-standard' in the event of a patient complaint.

He added: 'If there is a complaint and someone has not been following guidelines regarded as the gold standard, the complaint might be upheld.'

Dr Alan Hassey, a GP in Skipton, north Yorkshire and author of the guidance, said GPs were used to clinical governance, but had to become familiar with 'information governance' procedures.

'It needs to be put on a firm footing,' he said. 'GPs must understand the responsibility and we have provided them with one authoritative source they can dip in and out of.'

Sections in the guidance include detailed advice on when hard documents can be shredded and the type of computer file that is acceptable to store them.

There are also updated principles for recording clinical data, including the use of Read codes, how to assess education and training needs for GPs and staff and whether informed or implied consent from patients applies when using data from their notes.

Dr Paul Cundy, GPC IT sub-committee chair, said the document made clear practices had to accurately code morbidity otherwise their electronic records would be meaningless and they would not be able to set up systems necessary for the new contract.

'Some practices have been sloppy in their attitude towards a codified and structured record,' he said.

'The new contract may move that forward because GPs will come to understand the only meaningful data is structured data.'

He added practices needed to ensure no data was lost when they moved to an electronic record.

The guidance includes:

 · All responsibilities and liabilities of introducing and managing electronic patient records

 · Detailed advice on

·accessing data

·patient consent

·recording clinical data

·security of computer systems

·liabilities of transferring data

·keeping hard copies and when documents

can be shredded

 · Model checklists for going paperless as well as paperless accreditation models for PCOs

 · Education and training of GPs and staff

For a copy of the guidelines go to:

www.doh.gov.uk/pricare/computing/

Goodpracticeguidelineselectronicrecords0903.pdf

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