Medical records – ensuring continuity of care

GPs will be aware that they have strict data protection obligations regarding storage, access, retention and disposal of medical records when managing their practices on a day-to-day basis. These obligations will be enhanced by the General Data Protection Regulations due to come into effect on May 25, 2018.

When a GP decides to transfer his/her practice or to retire, their obligations regarding patients’ medical records continue during and after the transfer. To ensure continuity of care, GPs should make arrangements for the transfer of his/her patients to a new GP(s) and arrange for the safe and secure transfer of the patient records, while retaining a copy (or in the case of paper records, the originals) for themselves. 

If a GP is considering taking over a practice due to retirement, death or otherwise, it is very important to agree in advance of any takeover an arrangement in relation to current or archived patient records. It should be clear who will be responsible for the secure transfer, storage and if appropriate, disposal of those records.

Pitfalls

Without a proper plan in place for transfer or retirement, a number of issues can arise causing problems for GPs taking over a practice. Examples include: 

• GPs receiving patients’ records without consent and receiving deceased patients’ records 
• The workload associated with a mixture of paper and electronic records and subsequently dealing with record requests
• Consultation notes relating to more than one patient on the same record 
• Incomplete or inaccurate records and haphazard filing systems
• Requests for outstanding PMAs and medico-legal reports.

Advance notice

Time should always be factored into transfer or retirement plans so as to communicate with patients in advance. In the case of a retirement or death within a partnership or group practice, the GP’s patients should be informed and advised that their medical records are being retained within the practice for their continuing care. 

Where the patient advises that he or she wishes to transfer to another practice, then this request should be facilitated in the normal way.

GMS patients

In a typical GP practice, there will be a mix of GMS patients and private patients. GMS patients are doctor-specific, not practice-specific and if a GP moving from a practice intends to keep his/her GMS list, then it is necessary to liaise with the HSE regarding the change of address. The obligations under the GMS contract will continue to apply. Some GMS patients may prefer not to move with the GP who is moving from a practice and they can complete the necessary change-of-doctor form.

For GPs considering retirement, the GMS contract stipulates that three months’ notice must be given to the HSE.  The HSE will be involved in the allocation of the GMS list to another GMS GP to whom the records must automatically be transferred. A GMS patient can liaise with the HSE about choosing an alternative doctor and complete a change of doctor form.

Private patients

Private patients should be notified of a GP’s intention to retire or move practice and given an opportunity to move with the GP, to transfer to the GP taking over the practice or to transfer to a GP of their choice. On foot of the appropriate consent, their records should be transferred securely.  

Efforts to contact private patients should be made insofar as possible, as it is likely that some may no longer be in the area. If any patient cannot be contacted or does not respond within a reasonable period, the retiring or moving GP should retain the records securely for the appropriate retention period (see section on retention of records) and then safely destroy them.

All records

When records are being transferred, it is important to include all consultation notes, correspondence, test results etc whether in hard or soft copy. It is important for patient safety that a GP involved in a patient’s clinical management has access to up-to-date patient information and records. 

There is no specific timeframe for transferring patient records on the transfer of a practice; however the Medical Council ethics guidelines (see www.medicalcouncil.ie) state that doctors should facilitate the transfer of patient records ‘without delay’. 

A system should also be adopted to ensure any correspondence or tests results received in relation to a former patient is forwarded to their new GP without delay.

Secure transfer

The transfer of any patient records must be done in a secure manner such as via Healthmail. Healthmail is a secure clinical email system available free of charge which allows GPs and support staff to communicate sensitive information with clinicians in primary and secondary care and other stakeholders.  

If it is not possible to use Healthmail, any records being transferred electronically should be encrypted. The transfer of hard copy records should be done in person where possible or by registered post.

If a patient wishes to collect their own records or have them sent directly to them, a GP should get this request in writing. The GP must review the records carefully to remove references to third parties and check if there is anything in the records that could cause the patient harm. A patient collecting their records should sign a receipt.

Retention of records 

Under data protection legislation, data should not be retained for longer than is necessary. The Medical Council guidelines state that doctors should keep medical records for as long as they are likely to be relevant to the patient’s care, or for the period required by law or practice standards.  

When preparing for retirement or the transfer of a practice, it may be appropriate to dispose of older records once the applicable retention periods have expired.

The National Hospitals Office Code of Practice for Healthcare Records Management gives a helpful guide for retention of records and can be found on the HSE’s website (www.hse.ie). 

For adult patients, records should be kept for eight years after the last contact. The records of deceased patients should be kept for eight years after the date of death, or 10 years in the case of suicide. Medical records of children should be kept until the patient’s 25th birthday, or 26th if the patient was 17 at the conclusion of treatment. Different retention periods are provided for maternity records, records of those with a mental health disorder and patients in clinical trials.

A retiring GP or a GP transferring his/her practice must be mindful that medical records are often key evidence of care provided to patients in the event of a claim of negligence or a professional standards complaint.  

The GP should arrange to retain copies of patient records for the appropriate retention period in order to avoid a situation where they are reliant on the record-keeping practices of a third party. At the very least, a GP should negotiate and retain a right of access to records to be invoked if necessary.  

Secure disposal

Finally, any records that can be destroyed must be done securely. Hard copy records should be shredded or incinerated and electronic records should be permanently deleted.  

It may be necessary to take specific legal or IT advice to avoid some of the pitfalls that can arise in the transfer of a practice.