Basic Data Recording & Reporting

Consultation Forms

FGM Enhanced Dataset

Basic Data Recording & Reporting

C15E1

GP-05.3-01

Basic Data Recording - Data items

Record for every Consultation whether planned or unplanned any number of data items including as a minimum:

• Start date/time

• Staff Member(s) involved in the Consultation

• Organisation

• Location e.g. Practice, Patient’s home, hospital clinic

See Data Standards for coded data requirements, Appointments Management - GP - Standard for further requirements in relation to Consultations

MUST

C15E1

GP-05.3-02

Basic Data Recording - Patient characteristics/interventions

Ability to record Patient characteristics and interventions carried out to investigate or treat a Patient, including:

• Medical, family and social history

• Symptoms, signs, observations and investigation results

• Diagnoses, allergies, sensitivities and problems

• Surgical, diagnostic and preventative procedures

• Direct access services

• Counselling and health education

• Prescribing medicines and medical devices (see Prescribing - Standard)

The Solution will support the ability to record attachments

See Data Standards for coded data requirements

MUST

C15E1

GP-RC-2-01

Episode Recording

Ability to record the episode type of coded data (e.g. Diagnoses) as New or Ongoing/Other.

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

MUST

C15E1

GP-05.3-03

Basic Data Recording - Information about Patient Characteristics/Interventions

Ability to record the following information about each Patient Characteristic and Intervention:

• A coded clinical term (e.g. SNOMED CT), where available, identifying the Characteristic or Intervention

• A free text description

• One or more structured (including numeric) values, where relevant to an observation or to the result of an investigation

• The person carrying out the Intervention and their organisation (linked to Staff Member and cross-referencing Practice/related organisation)

• The date and time on which, or dates and times between which, the Characteristic applied or Intervention took place

• The date on which the Characteristic is to be reviewed

See Data Standards for coded data requirements, Appointments Management - GP - Standard for further requirements in relation to Consultations

MUST

C15E1

GP-05.3-04

Basic Data Recording - Call/Recall processes

Support the Practice in Call/Recall processes by:

• Recording that a Patient is subject to certain surveillance

• Manually recording recall or review dates

• Deriving and recording appropriate recall or review dates from other stored information (or lack thereof) such as demographic data and intervention start dates

MUST

C15E1

Child Competence Management

Support a Competence Assessment of a Child by recording the following:

• Date (pre-populated with current date – amendable by Practice User)

• Clinician (populated by a list of Practice Staff, default to logged on Practice User)

• Competence Decision 

  • Not Competent (set as default)

  • Competent

• Notes (free text)

This Assessment can be carried out multiple times – the most recent Competence Decision is to be used to determine competence-based access and capabilities regarding Citizen Services.

MUST

C15E1

GP-RC-3-01

Child Competence Management - Child not registered at the Practice

The Solution will support assessments of a Child where they are not registered at the Practice but has requested to become a Proxy for a Patient at the Practice.

MUST

C15E1

GP-PPFS-3.4-07B

'Not Competent' Child - Re-assessment timescale

Upon recording a Competence Decision of ‘Not Competent’ for a Child, Clinician to be given the ability to suggest a timescale for re-assessment.

See Recording Consultations - Standard v2.0.0#GP-PPFS-3.4-06 for recording Child Competence and Recording Consultations - Standard v2.0.0#GP-PPFS-3.4-08 for recording Adult Capacity 

MAY

C15E1

Adult Capacity Management

Support the Capacity Assessment of a Patient (Adult) by recording the following:

• Date (pre-populated with current date – amendable by Practice User)

• Clinician (populated by a list of Practice Staff, default to logged on Practice User)

• Capacity Decision (Has Capacity (default), Lacks Capacity)

• Notes (free text)

MUST

C15E2

GP-05.3-05

Call/Recall Reporting

Ability to generate a Patient-based report on calls and recalls (e.g. list of Patients whose review or recall date is due/overdue)

MUST

C15E3

GP-05.3-06

Planned/Unplanned Consultations Reporting

Ability to generate a report on:

• Planned Consultations (aggregate numbers of Consultations by service and/or organisation within a date range) - A Consultation with a Patient that is planned in advance, e.g. as the result of an Appointment.

• Unplanned Consultations (aggregate numbers of Consultations by service and/or organisation within a date range) - A Consultation that was not planned in advance. Includes out of hours, accident and emergency, NHS 111, and walk in centre Consultations.

MUST

C15E4

GP-05.6-04

Access Patient Record

Access a Patient Record where a Patient has been successfully identified, linked, listed or otherwise presented to the user.

MUST

Consultation Forms

C15E5

GP-05.4-01

Consultation Forms - Templates

Practice Users with appropriate system rights will have the ability to create, amend and delete Consultation form templates. Each template will have as a minimum:

• Unique identifier and/or name and version

• Template status (whether draft, published / available for viewing and use across the Solution, or obsolete)

• Basic business logic/rules, such as the ability to:

  • include defaults e.g. current date

  • auto-populate data items from within the Patient Record e.g. use of merge fields

  • auto-populate data items based on other data within the form

  • set mandatory data items

MUST

C15E5

GP-05.6-02

Consultation Forms - Template version history

Ability for Practice User to view version history and version content for a template.

MUST

C15E5

GP-05.6-03

Consultation Forms - Template version roll back

Ability to roll back to a previous version of a template.

MUST

C15E1

GP-05.4-02

Consultation Forms - Create

Create Consultation forms (using a published template - see Recording Consultations - Standard v2.0.0#GP-05.4-01) and launch other Consultation form templates from:

• Within the Patient Record

• Other modules within the Solution including Patient registration

MUST

C15E1

GP-05.4-03

Consultation Forms - View historical information

View historical information when entering data items, including:

• Any data items previously recorded via a version of the form

• Any pertinent data items previously recorded within the Patient Record

MUST

C15E1

GP-05.4-04

Consultation Forms - Saving information

Manage the completion and saving of a Consultation form. Practice User to have ability to:

• Save a partially completed form

• View a saved instance of a form

• Return to a saved form to continue data entry

• Mark a data entry form as complete

MUST

C15E1

GP-05.4-05

Consultation Forms - Obsolete forms

When a form becomes obsolete, Practice User to be able to:

• Complete data entry when in progress (using latest version of form if obsoleted due to an update)

• Access data previously recorded via the obsolete form template

MUST

C15E6

GP-05.4-06

Consultation Forms - Sharing forms

Support the sharing of Consultation form template(s) with other Practices on the same Solution.

For data entry form templates see Recording Consultations - Standard v2.0.0#GP-05.4-01

MUST

C15E7

GP-RC-1-01

Consultation Forms - Implement national forms

Implement and update Consultation form templates to support nationally contracted services ensuring they are available throughout the lifetime of the relevant service. Including, but not limited to:

• QOF

• GPES Data Extraction

MUST

FGM Enhanced Dataset

C15E1,  C15E8

FGM-ED-01

FGM Enhanced Dataset - SCCI2026

Enable capture of FGM data, and submission of captured data in the Patient Record - in accordance with SCCI2026 - FGM Enhanced Dataset

See , for specific requirements to support the ability to record, extract and upload the FGM Enhanced Dataset to the Clinical Audit Platform (CAP)

MUST