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Since December 2022, an ongoing phased implementation has enabled patients across England to access prospective information in their online GP health records.
This initiative currently applies to practices using the IT systems EMIS and TPP, but arrangements with Vision are not yet confirmed. Following the GP 2023/2024 contract announcement in April, legislation has been passed to make online record access automatic for all patients, except for exemptions or opt-outs, by October 31, 2023.
Going forward, GPs and other primary care staff who enter information into patients’ health records will need to consider the possible impact of each entry. Potentially sensitive information, such as test results and documents won’t be visible to the patient online until they have first been checked and filed, so clinicians will be able to contact patients first if necessary. GPs can also redact third party information or details that may cause significant harm. In some circumstances, access to records can be withheld to protect vulnerable patients who might be at risk from having online access to their notes.
The benefits of having access to online records are clear. Patients report it improves trust, enhances their understanding of their conditions, reinforces management plans, and allows them to take more control of their health.1 However, concerns have been raised about the readiness of redaction tools and the capacity of GP practices to adapt to automatic records access for all.2
The fact that patients will have instant access to their records does not change the purpose of the record. The care record still serves as a clinical tool to document patient care, informing colleagues and patients as to what’s going on. The record should also be seen as evidence of the care provided, should the standard or chronology of events ever be challenged. Medical record keeping should abide by the guidance set out in paragraphs 69 – 71 of Good Medical Practice 3.
The access to clinical records also provides an opportunity to improve care by using records access as a tool to engage and empower patients. As a communication tool, GPs can encourage patients to read and engage with their notes to ensure accuracy of the records. Feedback on inaccuracies should be encouraged and corrected. Safety-netting discussions can be reinforced by reminding patients they can revisit the documented plan at any time. As a collaboration tool, these records facilitate care planning, health literacy, transparency, trust, and self-monitoring.
Within this list, there are a few areas that warrant special attention from a medicolegal perspective:
Clinicians have been trained to write in a certain way, but now need to consider how language can be misinterpreted or cause offence. Terms such as “denies” or “excessive” carry judgment and can be avoided, for example, “alcohol consumption above recommended limits”. Caution is also advised where clinical words carry a different meaning to lay use, such as “chronic”.
In addition to inappropriate words or phrases, abbreviations can pose a challenge from an online access perspective and in civil claims. Abbreviations can often be personal and could be confused with other acronyms and therefore be hard to interpret. Where possible, only commonly acronyms should be used.
By using language that is descriptive and neutral, clinicians can be factual while avoiding judgment. For example, rather than using the word “unkempt”, an alternative could be “shirt untucked, food stains on clothes”. When describing observations, it can be helpful to use phrases such as “I observed that…” When referring to clinical opinions, consider “I think it could be…” or “the likelihood is that it is…”. It can also be useful to write “my impression is” before a differential diagnosis, as it makes it clear that it is an opinion.
Clinical encounters can be challenging and leave both the patient and clinician feeling frustrated or exasperated. It may be tempting to use the documentation as a catharsis of sorts, which could make it difficult to stay neutral and observational. Consider taking a break, and after reflection think about what aspects of the consultation would be most useful to document for clinical care.
One reason for restricting visibility of an entry in the notes or withholding online access may be because the clinical team is still considering whether online access is appropriate in a particular case. It is important to bear in mind that a Subject Access Request (SAR) grants patients access to their entire record, whether it was restricted for online access or not. When considering the threshold for non-disclosure in a SAR request, the practice could only withhold information where it relates to a third party (where they have not consented to disclose), or if it could seriously harm the patient. It is therefore important to document everything in a way that would be appropriate for patient viewing in the future, even if removed from online viewing at the time.
For further information on online access to records within primary care, you can visit the following resources: