Record Access - Patient

When any Record Access Level is enabled (at Practice or individual level), Patients to have access to relevant elements of the Patient Record as per Service Configuration (GP-SPFS-5.2-01), as a minimum.

All/any elements of a Patient Record marked as 'Restricted from View Record' will not be displayed to the Patient irrespective of Record Access Level Configuration.

e.g. Where Service Configuration determines Detailed Coded Record enabled with a Start Date of 1st February 2013 but a Clinician has reviewed a Patient’s Record back to 1st January 2010, any elements of the Patient Record not marked as ‘Restricted from View Record’ as part of the Record review/preparation (between January 2010 and February 2013) to display in addition to those displaying due to the Detailed Coded Record configuration.

Patients to have the ability to:

• Be informed upon every access that they might not be accessing the full information held using the following statement “This is a limited view of the Patient Record and may not include any free text. Information that is considered to be sensitive or that existed before the creation of this service may not be available for viewing online.”
• View relevant elements of the Patient’s Record logically grouped as appropriate, including:
  • The clinical term description i.e. not the code
  • Associated Free text
  • Date and Time of the Event
  • Source/Provenance (Organisation/System, User/Role, Name)
• Sort the Patient’s Record by relevant elements, including:
  • Event Date
  • Type
  • Problem (where available)
  • Source/Provenance (Organisation/System, User/Role, Name)

See the Patient Information Maintenance - GP Capability for Practice configuration of Record Access Levels.

Record Access - Proxy

When any Record Access Level is enabled (at Practice or individual level), Proxies to have access to relevant elements of the Patient Record as per Service Configuration (GP-SPFS-5.2-01), as a minimum.

All/any elements of a Patient Record marked as 'Restricted from View Record' will not be displayed to the Proxy irrespective of Record Access Level Configuration.

e.g. Where Service Configuration determines Detailed Coded Record enabled with a Start Date of 1st February 2013 but a Clinician has reviewed a Patient’s Record back to 1st January 2010, any elements of the Patient Record not marked as ‘Restricted from View Record’ as part of the Record review/preparation (between January 2010 and February 2013) to display in addition to those displaying due to the Detailed Coded Record configuration.

Proxies to have the ability to:

• Be informed upon every access that they might not be accessing the full information held using the following statement “This is a limited view of the Patient Record and may not include any free text. Information that is considered to be sensitive or that existed before the creation of this service may not be available for viewing online.”
• View relevant elements of the Patient’s Record logically grouped as appropriate, including:
  • The clinical term description i.e. not the code
  • Associated Free text
  • Date and Time of the Event
  • Source/Provenance (Organisation/System, User/Role, Name)
  • Translated elements of a Patient Record 
• Sort the Patient’s Record by relevant elements, including:
  • Event Date
  • Type
  • Problem (where available)
  • Source/Provenance (Organisation/System, User/Role, Name)

See the Patient Information Maintenance - GP Capability for Practice configuration of Record Access Levels.

Extract Patient Record - Patient

Ability to extract all or selected parts of the Patient’s Record in a suitable layout/format, including

• Printing
• Exporting/downloading

The output to detail the Source/Provenance of all such extracted data. 

Practice administrative data need not be provided e.g. document workflow actions.

Extract Patient Record - Proxy

Ability to extract all or selected parts of the Patient’s Record in a suitable layout/format, including

• Printing
• Exporting/downloading

The output to detail the Source/Provenance of all such extracted data. 

Practice administrative data need not be provided e.g. document workflow actions.

Record Access Level – Summary Information Record - Patient

The Summary Information Record Access Level will be the default. When set/enabled for a Patient, the Summary Information dataset (and *only* that data) will be made available irrespective of any agreement with the Patient regarding their actual Summary Care Record.

i.e. if certain information for the Patient is excluded from their Summary Care Record, this information will not automatically be excluded from the Summary Information record and vice versa. 

The Summary Information Record dataset includes medications, allergies and adverse reactions – specific requirements are as defined within the Summary Care Records requirements documentation.

See the Patient Information Maintenance - GP Capability for Practice configuration of Record Access Levels.

Record Access Level – Summary Information Record - Proxy

The Summary Information Record Access Level will be the default. When set/enabled for a Patient, the Summary Information dataset (and *only* that data) will be made available irrespective of any agreement with the Patient regarding their actual Summary Care Record.

i.e. if certain information for the Patient is excluded from their Summary Care Record, this information will not automatically be excluded from the Summary Information record and vice versa. 

The Summary Information Record dataset includes medications, allergies and adverse reactions – specific requirements are as defined within the Summary Care Records requirements documentation.

See the Patient Information Maintenance - GP Capability for Practice configuration of Record Access Levels.

Record Access Level – Detailed Coded Record - Patient

Adhere to the following requirements regarding Detailed Coded Record Access:

• Include all data held as coded data (See Data Standards for definition of coded data and associated requirements) within the Patient Record, excluding associated free text
  • Where free text associated with coded data has been marked as ‘Restricted from View Record', this will not be displayed to the Patient.
• Build upon the data provided to the Patient via the Summary Information Record; as such the Detailed Coded Record cannot be enabled without the Summary Information Record also being enabled. This is the case for all levels of Service Access – Practice configuration, Patient Record level and VUA-Patient Association level.

See the Patient Information Maintenance - GP Capability for Practice configuration of Record Access Levels.

Record Access Level – Detailed Coded Record - Proxy

Adhere to the following requirements regarding Detailed Coded Record Access:

• Include all data held as coded data (See Data Standards for definition of coded data and associated requirements) within the Patient Record, excluding associated free text
  • Where free text associated with coded data has been marked as ‘Restricted from View Record', this will not be displayed to the Proxy.
• Build upon the data provided to the Proxy via the Summary Information Record; as such the Detailed Coded Record cannot be enabled without the Summary Information Record also being enabled. This is the case for all levels of Service Access – Practice configuration, Patient Record level and VUA-Patient Association level.

See the Patient Information Maintenance - GP Capability for Practice configuration of Record Access Levels.

Record Access Level – Document Access (Clinical and Administrative) - Patient

Adhere to the following requirements regarding Document Access:

• Ability for Patients to be able to view all clinical and administrative documents where configured by the Practice.
• Patients will not be able to view Pathology and Radiology test results if they have not been reviewed by the Practice.
• Patients will not be able to view Documents if they have not been reviewed by the Practice.

See the Patient Information Maintenance - GP Capability for Practice configuration of Record Access Levels

Record Access Level – Document Access (Clinical and Administrative) - Proxy

Adhere to the following requirements regarding Document Access:

• Ability for Proxies to be able to view all clinical and administrative documents where configured by the Practice.
• Proxies will not be able to view Pathology and Radiology test results if they have not been reviewed by the Practice.
• Proxies will not be able to view Documents if they have not been reviewed by the Practice.

See the Patient Information Maintenance - GP Capability for Practice configuration of Record Access Levels

Record Access Level – Full Record - Patient

Adhere to the following requirements regarding Full Record Access:

• Clinical data held within the Patient Record (coded or otherwise i.e. includes free text data associated and not associated with clinical codes e.g. Consultations, Medications, Pathology Results)
• Demographic and Patient administrative data
• Documents associated with or embedded within the Patient Record, including annotations associated with any documents.
• Pathology and Radiology test results.

See the Patient Information Maintenance - GP Capability for Practice configuration of Record Access Levels.

See E00171 and E00172 in the Patient Information Maintenance - GP Capability for start date restrictions.

Record Access Level – Full Record - Proxy

Adhere to the following requirements regarding Full Record Access:

• Clinical data held within the Patient Record (coded or otherwise i.e. includes free text data associated and not associated with clinical codes e.g. Consultations, Medications, Pathology Results)
• Demographic and Patient administrative data
• Documents associated with or embedded within the Patient Record, including annotations associated with any documents.

See the Patient Information Maintenance - GP Capability for Practice configuration of Record Access Levels.

See E00171 and E00172 in the Patient Information Maintenance - GP Capability for start date restrictions.