Policy for the Recording of Patient Information


Patients’ medical records should accurately reflect the medical conditions, care and treatment they have experienced over time. This is necessary for good continuing patient care and for medico-legal reasons. The records should therefore be correct, complete and, where possible, contemporaneous.

This policy applies to all GP principals, employed locums and assistants, practice-employed staff, and others working within the practice.

The Practice’s legal bases for collecting, storing, processing and destroying personal and medical information about patients under GDPR are:

Article 6(1)(e) – Public task

Article 9(2)(h) – For the purpose of preventative and occupational medicine

The highest standards of governance must be applied in recording, storing and disposing of patient information, in line with Caldicott principles, the Data Protection Act, General Data Protection Regulations and other legislation and regulations in force.

This policy should be read in conjunction with the following:

  • Confidentiality and consent to the disclosure of confidential information
  • Summarising policy
  • IM&T policy
  • Home visits protocol

Recording contacts with patients

  1. All patient consultations and other encounters/contacts with/about patients must be recorded in the computer record, whether they have been undertaken at the surgery, as a home visit, by telephone, text, email or letter. The encounter must reflect the place/type of consultation.
  • Entries should be linked to the relevant problem title in the patient’s summary where appropriate. The problem will generally be a diagnosis rather than a symptom or procedure.  New problems should be added using the correct read/Snomed code. Long-term conditions and single episode problems must be added as a problem once only.
  • Active problems should include long-term conditions and chronic diseases, conditions currently under treatment by medication or under hospital care and those currently symptomatic.
  • Other problems should be classified as Past Significant if likely to recur or have a future impact on the patient’s health and wellbeing, or otherwise Past Minor.
  • Consultations should include details of the presenting problem, examinations undertaken, differential diagnoses, medication prescribed and care plan (investigations, medication changes, action to take for red flags, referrals, follow-up arrangements, etc).
  • Unconfirmed or differential diagnoses should be entered as free text under the symptom code, or the Uncertain Diagnosis code (R2).
  • Visit requests should be recorded on the EMIS Web Home Visit page. This record should then be annotated by the practitioner as appropriate when taking ownership of the visit and then updating the patient’s notes afterwards e.g. by adding in clinical findings and advice/treatment following the visit or consultation by telephone.
  • Templates should be used to input clinical data (where available).
  • Telephone, email and online consultations must be recorded in the same way as a face-to-face consultation, under the correct place of encounter.
  1. Where a patient is accompanied, details should be recorded. In the case of children aged under 16 years it must also be recorded if the patient is unaccompanied.


  1. Acute and repeat prescriptions must be recorded on the computer, even if hand-written, for example at the patient’s home and whether the items have been prescribed by a GP principal, locum, or nurse.
  1. All prescriptions must be linked to the associated problem title.
  1. Drug allergies must be coded into the appropriate section of the medical record, using the add allergy function in EMIS Web.

Path Lab Links

  1. Laboratory test results are received daily and are transferred into the patient’s medical record.
  1. The links team must allocate path links information to the correct practitioner and ensure that it is correctly re-directed if the practitioner is absent (e.g. on annual leave).
  1. Practitioners must go through their links information on a regular basis at least daily, and annotate as appropriate. Actions must be recorded from the picking list and full details provided in tasks sent.
  1. The links team must ensure that patients are notified of test results if advised by the GP and that follow-up is acted upon, e.g. contact the patient to inform them to collect a prescription or to make an appointment in line with the confidentiality policy.

Hospital/unscheduled care and scanned documents

  1. Hospital clinic letters must be processed as quickly as possible, especially those requiring follow-up action such as a prescription, using the workflow protocol.

Clinical Summaries

  1. Most patient records now arrive by GP2GP and contain a summary. For records received without GP2GP a brief summary must be requested and summary details coded. Lloyd George records must be summarised for these patients as soon as possible after receipt by the practice in line with the Network summarising protocol.
  • Summaries must be kept up to date by ensuring that new diagnoses, investigations, operations and procedures etc are coded on using agreed codes and location within the record (active/past problem, health admin, significant/minor).

Other Patient Information

  • Relevant personal information should be recorded appropriately to alert practitioners to their special needs. Examples include:
  • On child at risk register
  • History of violent/aggressive behaviour
  • Terminally ill
  • Is a carer or has a carer
  • Housebound
  • Disabilities (blind, deaf, wheelchair-bound, etc)
  • Special communication needs (large print, braille, easy read, etc)
  • Complaints made by the patient should not be entered onto the medical record. This information should be held separately.
  • GMS1 forms should not be scanned on. These should be retained for three years then confidentially destroyed.
  • New patient health check forms can be shredded once the information has been inputted.
  • Requests for medical information, such as copies of records, PMA reports etc, should be recorded under Medical Report Requested in Health Administration, so that progress can be tracked as necessary.

Changes in Circumstances

  • Change of name, address or telephone number must be processed as quickly as possible using the current protocol. The practice will, from time to time, send Data Quality forms to patients, in order to update personal information.
  • Health visitors should be informed of detail changes for patients aged under five years.
  • Details of patients who have died must be processed using the Deaths protocol.

Destruction of medical records

  • Letters and reports that are scanned onto the computer must be placed in the secure shredding bins for confidential disposal.
  • DNACPR forms should not be shredded, but should be filed in the patient’s Lloyd George record.
  • Duplicate expired and irrelevant data must be removed from Lloyd George records and confidentially destroyed in line with the Summarising protocol and in line with current NHS guidelines on the retention and destruction of medical records.
  • Data should not usually be deleted from the computer medical record unless it is duplicated data.

NB – Patient-identifiable data should not be recorded in staff members’ personal diaries and notebooks, which might be taken home with the risk of accidental breach of confidentiality.