PI Brief Update

What Information should GPs record? - Dr Mark Burgin

21/01/21. Dr. Mark Burgin BM BCh (oxon) MRCGP explains that GPs can record too much information and cause breaches of confidentiality.

General practitioners use the biopsychosocial model so they typically record information about their patient’s social life that other doctors would not.

This information can include sensitive issues such as domestic problems, criminal behaviour and sexuality as well as psychological and reproductive issues.

The increase in requests for copies of the medical records and the fall in cost has meant that GP can no longer expect what they write to be confidential.

In the past GPs stored sensitive issues in their memories but as few practices are small enough for this to be possible new methods are required.

Recording a sensitive issue

GPs have a responsibility to record those aspects of the medical history that are relevant to their care for the patient but most sensitive issues fall into this category.

Where a patient discloses a sensitive issue the GP should consider whether this is information that is necessary for the care of the patient or is useful for another purpose.

There is a strong argument for there to be a separate file for sexual and reproduction (particularly for women who almost universally have records).

Recording e.g. psychological problems as ‘had a chat’ is unacceptably poor practice as this is in breach of GMC good medical practice 2013.

Separate systems for sensitive records

General practitioners are data controllers and can process data for reasonable objectives whether this is in the GP records or in another form.

The GMC does not say that all entries must be stored in the NHS records so there are no rules to prevent GPs from having a separate file.

GPs should take reasonable steps to maintain a separate system for records that should not ordinarily be disclosed for legal cases.

The main records should contain a note that a separate record exists so that if appropriate the records can be viewed.

Requests for medical records

Having a separate system for sensitive records would have a substantial advantage apart from improving patient’s (low) confidence in confidentiality.

Hospitals typically keep psychiatric records separate from other medical records so that they are not included within a normal request for records.

GPs would be able to rely upon the medical records being suitable to be sent to a lawyer without needing to check them and thus save time.

In the rare situations where the sensitive records are required the GP could insist on more information than a signed consent form.

Conclusions

The current (default) system is not working with public disquiet about their medical records being provided in low level civil courts such as for personal injury (also see care.data scheme)

Redacting from medical records takes excessive effort and is a fail-dangerous system where even one mistake may breach confidentiality.

GPs need to record sensitive details of patients’ psychosocial history to provide good quality care but many GPs are not making any records as they know they are not confidential.

Holding records on criminal activity such as sexual offences against children and domestic abuse would further increase the risk of a GP in breach of confidentiality.

Doctor Mark Burgin, BM BCh (oxon) MRCGP is on the General Practitioner Specialist Register and audits medical expert reports.

Dr. Burgin can be contacted This email address is being protected from spambots. You need JavaScript enabled to view it. and 0845 331 3304 website drmarkburgin.co.uk

Image ©iStockphoto.com/dra_schwartz