Contract deal for 2015/16 to change how GPs write records

GPs will be forced to change the way they write GP records, warns a GPC member, as new contract agreements for 2015/16 will allow patients to access 'detailed information' from their GP record.

Dr Paul Cundy: GPs must learn to write records for two audiences (Photo: Pete Hill)
Dr Paul Cundy: GPs must learn to write records for two audiences (Photo: Pete Hill)

Contractual agreements last year allowed patients to access limited information on their record in the form of the summary care record (SCR), but the GPC confirmed that patients who were interested would soon be able to access even more of their information.

Dr Paul Cundy, chairman of the joint GPC and RCGP IT committee, said the move to allowing greater record access would herald huge changes, and GPs would have to get used to writing records for two audiences instead of just one.

Commencing for the 2015/16 year, the GPC has agreed that patients who make an active application to their practice will be able to access detailed records comprising of ‘read coded’ information.

This will allow patients to read and understand the clinical information on their record in plain English, which is usually coded in rubric format.

Entitled to withhold information

GPs will be legally entitled to withhold certain information ‘where they judge it to be in the patient’s interest or where there is reference to a third party’, according to a letter sent out to the profession by GPC chairman Dr Chaand Nagpaul.

This is in accordance with the data protection act, and can include a range of information such as suicide risk, prognosis and information that can be linked to other family members.

There is also an option for GPs to make free text inaccessible to patients, as some of this information could be inappropriate for patients to see.

Writing for two audiences

Dr Cundy said allowing online record access would force GPs to change the way they write patient records.

He said: ‘It is inevitable that patients should have access to their record. But we need to manage migration for doctors as much as patients. For the last 50 years, GPs have written records with one audience in mind, those being the people they work with.

'But this agreement signals a transition to writing records where there are now potentially two audiences: the people they work with and their patients. And that is not something that can be achieved in one year’s minor contractual tweaking.’

Read more: Named GP for all patients as 2015/16 contract revealed

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