The Good Practice Guidelines for GP electronic patient records

Table of Contents

1. Strategic Context for the Good Practice Guidelines for GP electronic patient records v4 (2011)

   1.1 Introduction 1.2 Background 1.3 GPGv4 scope and definition 1.4 GPGv4 content

2. The Purposes of Health Records

   2.1 Clinical purposes 2.2 Non-clinical purposes 2.3 Additional purposes 2.4 Emerging purposes

3. Clinical Safety Assurance

   3.1 Introduction 3.2 Clinical safety approach 3.3 Clinical safety assurance and inter-operability 3.4 Current NHS safety standards for IT systems 3.5 Future safety standards including changes to the medical device directive

4. Records Governance

   4.1 Information governance framework

   4.2 Legal aspects 4.3 Standards 4.4 Other relevant publications 4.5 Governance issues particular to shared patient records

   4.6 Records and record keeping -- guidance from health professional bodies 4.7 Consent 4.8 Information governance and data disclosure 4.9 Retention of GP electronic patient records and associated audit trails when a patient is no longer registered with a practice

5. Shared Electronic Patient Records

   5.1 Introduction 5.2 Shared electronic patient records -- background 5.3 Sharing records with patients (Record Access)

6. High Quality Patient Records

   6.1 Introduction 6.2 Information quality and modern general practice 6.3 Capturing information in the consultation 6.4 Capturing information from outside the practice 6.5 Recognising high quality patient records 6.6 System-specific issues 6.7 Data quality and shared records 6.8 Conclusion

7. Clinical Coding Schemes

   7.1 Coding schemes in current use 7.2 Future standardisation of coding schemes across health care. SNOMED-CT 7.3 Features of Read Codes 7.4 General issues relating to terminology use 7.5 Sharing coded information 7.6 Preparing to move to SNOMED-CT, what to expect

8. Data Transfer & Interoperability

   8.1 Introduction 8.2 Clinical safety assurance 8.3 Chapter organisation

8a The Personal Demographic Service

8a1 Introduction

8a2 Access & security

8a3 PDS tracing

8a4 The NHS Number (England & Wales)

8a5 Data quality

8b GP2GP Electronic Record Transfer

8b1 The rationale for electronic GP2GP transfer

8b2 The nature of electronic GP2GP transfer

8b3 The limits of electronic GP2GP record transfer

8b4 General clinical safety

8b5 Electronic and paper GP2GP record transfer

8b6 GP electronic record quality

8b7 GP2GP record transfer -- good practice guidelines

8c Data Migration

8c1 Formalising the process of data migration

8c2 Data migration process

8d Clinical Messaging

8d1 Introduction

8d2 Background

8d3 Processes involved in handling clinical messaging data transfers

8d4 Pathology

8d5 Radiology

8d6 Out of hours (OOH)

8d7 A/E encounter, outpatients encounter, inpatients discharge

8e The Summary Care Record and Emergency Care Summary

8e1 Introduction

8e2 Consent

8e3 Data quality

8f High Quality Medication Records & The Electronic Prescription Service

8f1 Introduction

8f2 High quality medication records

8f3 Why is the EPS service being introduced?

8f4 Different releases in EPS

8f5 EPS release 2

8f6 Getting ready for EPS

8f7 EPS consultation process

8f8 Benefits for patients and carers

8f9 Benefits for prescribers

8f10 Smartcards

8f11 Release 2 readiness (& figure)

8f12 Security & confidentiality

8f13 Access control

8f14 EPS unsupported prescriptions

1. A Pathway to Good Paperless Practice

   9.1 Introduction 9.2 About this chapter 9.3 From paper to paper-free 9.4 Pre-requisites 9.5 Benefits and risks 9.6 Data quality recording standards 9.7 Moving practice business to paper-light 9.8 System user-groups 9.9 Accreditation of paperless practices

2. Electronic Document Attachments

   10.1 Introduction 10.2 Attached electronic documents 10.3 Format of attachments 10.4 Storage of attachments 10.5 Attachment identification and coding 10.6 Transferring attachments 10.7 e-referral attachments 10.8 Other documents

3. Working in an e-business Environment

   11.1 Introduction 11.2 Working in an e-business environment 11.3 NHS connectivity 11.4 Practice web sites and on-line services 11.5 'Consumer' orientated Internet health services 11.6 Using the Internet for consulting 11.7 Supporting general practice 11.8 Privacy and security in the online world 11.9 Data extracts

4. Education and Training

   12.1 Why education and training are important 12.2 Learning needs 12.3 Meeting these learning needs 12.4 Some learning resources Appendix Glossary