The National Health Service (General Medical Services) Amendment (Wales) Regulations 2001

36Records

1

In this paragraph, “computerised records,” means records created by way of entries on a computer.

2

A doctor shall keep adequate records of the illnesses and treatment of his or her patients, and shall do so—

a

on forms supplied to the doctor for the purpose by the Health Authority; or

b

subject to sub-paragraphs (3) and (4), by way of computerised records,

or in a combination of these two ways

3

Where a doctor proposes to keep computerised records, he or she shall first obtain the written consent of the Health Authority.

4

The Health Authority shall consent to a doctor’s application to keep computerised records if it is satisfied that—

a

the computer system upon which the doctor proposes to keep them has been accredited by the National Assembly for Wales or another person or body on its behalf in accordance with the principles set out in “General Medical Practice Computer Systems - Requirements for Accreditation - RFA99 (Wales)”3;

b

the security and the audit trail measures incorporated into the computer system as accredited in accordance with sub-paragraph (a) have been enabled; and

c

the doctor is aware of, and has signed an undertaking, that he or she will have regard to, the guidelines contained in “Good Practice Guidelines for General Practice Electronic Patient Records (Wales)”4,

and the Health Authority may withdraw its consent if it ceases to be so satisfied.

5

Where a doctor keeps computerised records he or she shall, as soon as possible following a request from the Health Authority, allow the Health Authority access to the information recorded on his or her computer system including access to the audit trail measures referred to in paragraph 4(b).

6

A doctor shall send the records relating to a patient to the Health Authority—

a

as soon as possible, at the request of the Health Authority; or

b

where a person on the doctor’s list dies, before the end of the period of 14 days beginning with the date upon which the doctor was informed by the Health Authority of the death, or (in any other case) before the end of the period of one month beginning with the date on which he or she learned of the death.

7

To the extent that a patient’s records are computerised records, a doctor complies with sub-paragraph (6) if he or she sends to the Health Authority a copy of those records—

a

in written form; or

b

with the written consent of the Health Authority, in any other form.

8

The Health Authority shall consent to the transmission of information other than in written form for the purposes of paragraph (7)(b) if it is satisfied with the following matters—

a

the doctor’s proposals as to how the records will be transmitted;

b

the doctor’s proposals as to the format of the transmitted records;

c

how the doctor will ensure that the records received by the Health Authority are identical to those transmitted; and

d

how a written copy of the records can be produced by the Health Authority,

and the Health Authority may withdraw its consent if it ceases to be satisfied as to any of the above matters.

9

Where a doctor keeps computerised records he or she shall not disable, or attempt to disable, either the security or the audit trail measures referred to in paragraph (4)(b).