Patient Information

Online Account and Service Management

Subject Access Requests

Patient Information Reporting

Patient Information

C13E1

GP-04.1-01

Patient Registration

Support Patient registration at a General Practice for all Medical Services

MUST

C13E1

GP-04.1-02

Patient Registration Types

Categorise Patients using Registration Types in line with legislative registration statuses as defined in NHS England Standard General Medical Services Contract (see definition of 'Patient' in Part 1)

Additionally, provide the ability to categorise Private patients using a specific Registration Type.

MUST

C13E1

GP-04.1-03

Patient Registration Personal Data

Enforce the following Minimum Data Set at point of Patient registration (prior to clinical data being recorded)

• Family Name

• Forename

• Date of birth

• Sex

• Registration Type (in line with legislative registration statuses):

  • Fully Registered

  • Temporary Resident

  • Immediately necessary treatment

  • Private

  • Other

• Registration start date

• Registration status (active/inactive)

• Communication needs for the Patient

See PDS for demographic data format.

For contractual references between GPs and NHSE see: NHS England Standard General Medical Services Contract

MUST

C13E1

PIM9

Patient's GP

Record:

• a Usual GP

• a Named Accountable GP

• an Individual GP for Specific Services (e.g. Child Health Surveillance services) - only applicable for Patient Registration Types of Other and Private (see GP-04.1-02)

MUST

C13E1

PIM10

Registration End Date

Record an end date for each Registration Type.

If the Registration type is Fully Registered and the Patient has been Deducted the Registration end date must equal the Deduction date.

MUST

C13E1

GP-04.1-05

Patient Verification

Support Patient verification during the registration process with comprehensive tracing functionality.

See PDS for details on PDS Advanced Trace functionality

MUST

C13E1

GP-04.1-07

Patient Registration Status

Automatically update a Patient’s Registration Status if/when registration start date, registration end date (or date of Deduction) is completed:

• Active

• Inactive

See GP2GP documentation for details of Patient registration and GP2GP trigger conditions

MUST

C13E1

GP-04.1-08

Re-activate Inactive Patient

Reactivate an Inactive Patient Record when a Patient re-registers with a General Practice (e.g. prisoner released) i.e. another instance of a Registration Type can be created for the Patient, but the original end date will not simply be deleted.

See GP2GP documentation for specific Electronic Patient Record transfer requirements on returning Patients

MUST

C13E1

PIM8

Record and Maintain Demographic Information

Record and maintain the following national Demographic Information for all registered Patients:

• Patient’s Responsible GP

• Patient’s Responsible HA (hospital authority)

• Patient’s GP Practice

• NHS Number

• Family Name

• Former Family Name

• First Given Name

• Other Given Names

• Preferred Name

• Alias/Also Known As

• Title

• Sex

• Date of birth

• Address

• Post Code

• At least one previous home address

• At least one telephone contact

• At least two other contact types (e.g. email, work tel number)

• Preferred language (spoken)

• Place of Birth

• Drugs Dispensed Marker

• RPP Mileage

• BR/SD marker

• Walking Units

• RI code

Requirements for the format of these data fields can be found in the relevant NHAIS and PDS documentation – if they differ, Solutions will adhere to both formats when synchronising and transferring data between Solutions (e.g. NHAIS Requirements for address format are more prescriptive than those for the address format for PDS)

See GP-PPFS-3.4-02 for notifications around demographic and preference changes

MUST

C13E1

GP-04.2-02

Record and Maintain Additional Demographic Information

Record and maintain the following additional Demographic Information for all registered Patients:

• Marital status

• Religion

• Ethnic Category

• Interpreter required

• Transport needs

• Advocacy needs

• A previous NHS number (including old style NHS numbers)

• Usual GP

• The location normally attended

• Address access notes (information about how to access a Patient’s home e.g. door code values or ‘use back door’ – not to be included within standard address details or synchronised with National Systems)

• A telephone number with its category e.g. Mobile

• Email address

• Whether the Patient is cared for / has a Carer

• Whether the Patient is also a Carer for another individual(s) irrespective of whether those individuals are registered Patients with the General Practice

MUST

C13E1, C13E4

GP-04.5-01A

Record and Maintain Preference Details

Record and maintain the following Preference details for each registered Patient, each data item in its own explicit field(s) with values determined from standard lists wherever possible:

• Gender  

  • Allow the gender and sex to be recorded as different data items with potentially different content

• Preferred written language

• Preferred spoken language

Default will always be implied dissent and for each Preference default to be ‘not yet set’ – any changes will be on an individual Patient basis

See GP-PPFS-3.4-02 for notifications around demographic and preference changes

MUST

C13E1

Patient Alerts

Add, update and remove Patient Alerts manually or automatically (e.g. rules based), to indicate key characteristics to Practice Users (e.g. that the patient is violent or is on a certain chronic disease register).

MUST

C13E3

GP-04.4-01

Record and Maintain Related Persons

Record and maintain the following related persons for all registered Patients, each data item in its own explicit field(s) with values determined from standard lists wherever possible.

A Patient can have multiple related persons, a person can be related to multiple Patients and an individual can be a related person of multiple types to a single Patient:

• Related person type - examples include:

  • Carer

  • Next of Kin

  • Cared for Individual / Caree

  • Psychiatric nurse

  • Patient's social worker

• Relationship to Patient

• Family Name

• Given Name(s) / Forename(s)

• Title

• Sex

• Organisation name (to support situations where Patient is in the care of a home rather than a specific individual working at the home)

• Address

• At least one telephone number (and associated category e.g. Mobile)

• Email address

• Source of a related person’s information (who has given information regarding the relationship) e.g. Patient, Carer, other Health Provider Organisation 

• Notes about the relationship – free text

Where the related person is also registered at the Practice, this related person record can be derived from / linked to their Patient Record

MUST

C13E8

GP-05.1-01

Search, identify and retrieve a Patient Record

Search for, identify and retrieve a Patient Record for use in the Solution by searching full or part of the contents of any combination of the following fields:

• Family name

• Given name / Forename (including first or other names)

• Preferred name/Alias/Also known As

• Date of birth

• NHS Number

• Address

• Postcode

• Telephone number

• Registration Type

• Local Patient identifier

MUST

C13E8

GP-05.1-02

Find Record with Demographic Changes

Ability for Practice User to explicitly select to include historic Demographic Information in a search

MUST

C13E2

GP-05.1-03

Notification of Patient Record Actions

Indicate to the Practice User:

At any point a Patient interacts with the Practice / when accessing a Patient’s record:

• About the incompleteness of a registration record

• Where contact details have a status indicating that they require re-verification e.g. where mail has been returned or emails bounced back

• If a task is outstanding for that Patient

• Of any outstanding Referrals

• Of any documents with a status indicating that they are not Filed and/or document properties (header file / document metadata) have not been recorded, or documents recorded as Provisionally Filed (including via/within a Citizen Service)

Irrespective of the solution where a Practice User is Notified / Informed of any of the above, a Practice User is to have the option to directly access the relevant area of the Solution or specific information to enable rectification

MUST

C13E2

GP-05.1-04

Access Patient Record with Matched Item

Access a Patient Record from any area or module within the Solution where a Patient has been successfully matched or linked to the item/area e.g. when viewing a document or managing a task, a Practice User can directly open/launch the associated Patient Record

MUST

C13E1

GP-05.2-01

View Events and Future Activities

View all historic events and future activities planned within a journal or Patient activity log, including:

• Consultations / Encounters

• Medication

• Characteristics and Interventions

• Documents

• Tasks

• Allergies

MUST

C13E1

PIM17

Problem-orientated records

Support a problem-orientated approach to recording and viewing data, including:

• Ability to define Problems (using appropriate coding as per Data Standards)

• Ability to maintain Problem lists

See Good Practice Guidelines for GP electronic patient records Version 4 (2011) for guidance

MUST

C13E1

GP-05.2-02

Access Data Items

Identify and access related data items and documents irrespective of:

• Mechanism used to organise screen display

• Provenance – where or by whom an encounter or event occurred

• Activity progress, completion dates or statuses

All pertinent information will be accessible to the Practice User  e.g. when viewing a battery of test results, the result type, value, the unit of measure, the clinician and dates (such as date sample taken, date test requested, date test performed, date results received) will be available together for each of the tests within the received result

See Role-based Access Control for required access controls

MUST

C13E1

PIM15

Organise Patient Record

Organise to make optimal use of the record by any combination of the following mechanisms:

• Creating/maintaining a personalised display of a Patient Record that can be saved and applied to all Patient Records as a Practice User’s default (User defined structure and layout of the order of certain elements of a record) 

• Sorting/ordering – ad-hoc re-ordering of the content of a Patient Record chronologically and by any particular data item or groups of data items e.g. date of consultation / Encounter

• Filtering and grouping – identifying a subset of the record based on the type or value of a data item e.g. show all unplanned service Encounters grouped by contact types (out of hours, A&E, NHS111) or display/exclude all entries featuring a certain range of clinical codes recorded within a date range

It will be obvious to a Practice User when a record they are viewing has been grouped, filtered and/or sorted/ordered.

MUST

C13E1

PIM16

Filter record on 'Restricted from View Record' items

Ability to filter the Patient Record (as described in PIM15) on those items marked as 'Restricted from View Record' (see PIM14)

may

C13E1

GP-05.2-04

Search a Patient Record

• Using all/any combination of coded or structured data held within or linked to the Patient Record

• For a specified text string across both structured data (including clinical terms) and free text fields

• For a document using classification and/or document properties (header file / document metadata)

See Data Standards for coded data requirements

MUST

C13E1

PIM13

Search within Documents

Ability to search the contents of Documents attached to a Patient Record for a specified text string across both structured data (including clinical terms) and free text.

MUST

C13E1

GP-05.2-05

Print/Export Patient Record

Practice User to have the ability to Print/export the entire Patient Record with the ability to select to also print/export:

• Attached documents or a selection thereof

• Audit Trails

MUST

C13E11

GP-13.1-01

Patient Outside of Catchment Area

Indicate to a Practice User that a registered Patient is residing outside of the catchment area of the Practice.

See Patient Choice Scheme and out of area registrations for background information.

MUST

C13E1

PIM7

Sexual orientation Monitoring (DCB2094)

Adhere to the Sexual orientation Monitoring (DCB2094) Standard.

MUST

 Citizen Account and Service Management

C13E4, C13E10

Service Access - Patient

• Have the ability to enable or disable the following Citizen Services at a Practice level and Patient level:

  • Communicate with Practice - Citizen

  • Appointments Management - Citizen

  • Prescription Ordering – Citizen

  • View Record - Citizen - the Practice will be able to configure access to the following Record Access Levels:

    • Summary Information Record

    • Detailed Coded Record

    • Document Access (Clinical and Administrative)

      • only to be available if Detailed Coded Record is also enabled

    • Full Record

MUST

C13E20