Notes Transfer Policy

Code: POL 3

Date: 17/06/2014

Reviewed:  23/07/2023,07/02/2016

Purpose:

To ensure that patients receive continuity of care by ensuring clinical records are transferred to new providers in a timely and efficient manner.

To protect patient confidentiality by ensuring that notes are transferred by secure means.

To ensure that the practice complies with regulatory expectation as regards the timeliness and security of notes transfer.

Responsible Staff:

Implementation: Practice Administrator

Action: Reception Staff

Audit: Practice Administrator

Audit:

Training Resources:

The Code of Health and Disability Consumer's Rights

Linked Policies:

Health Information Privacy Policy

Policy:

Requests for transfer of medical records.

Requests for the transfer of medical records may be made by a client either verbally or in writing.

In the case of a verbal request, the fact of the request, including the date and time must be recorded by the staff member receiving the request. It is important to make an effort to identify the client positively. Confirm their full name, address, date of birth and phone number.  Wherever possible, the client should sign a copy of the record, which should then be used as a written transfer request.

In the case of a written request, ensure that it is signed, contains accurate information and that consent for the transfer of notes has been given specifically.

Whilst a signed enrolment form alone is not evidence of consent for the transfer of records, the transfer is implicit in enrolment and notes transfer should not be unduly delayed. If an enrolment form is received which does not include consent for transfer, the staff member receiving the request should attempt to contact the client as soon as possible to establish their intent. Notes transfer may then proceed if verbal consent is received.

Transfer of medical records for clients aged over 16 requires the specific individual consent of the client. A parent or guardian cannot give this consent on their behalf.

In general, consent for records transfer may be given by a guardian for clients under the age of 16, however in the case of clients where the guardian lives at a different address from the client, the reason for the transfer should be sought by attempting to contact the person who signed the request form.

Clients under 16 who are competent may sign their own forms. Most clients over 12 years of age will be competent.

The Transfer of the Records

Wherever possible, records shall be sent by electronic means.  This should generally be GP2GP.

The use of healthdocs to transfer records is not appropriate as it is not fully integrated into several commonly used software systems and is very difficult to use at present.

Email is not generally appropriate for the transfer of clinical information though it may be used:

• If it is specifically requested by the client that email be used.

• To transfer a minimal data set to aid emergency treatment (such as for a client who is overseas)

• To aid diagnosis (such as the transfer of clinical images) via telemedicine.

• Provided that in all cases, the client has been advised that email is not a secure method of notes transfer and that the data may be viewed by others.

Where possible, email communication should not use readily identifiable client information.

The use of facsimile for transmission of notes is not appropriate.

GP2GP is the preferred method of transferring notes. Large files may need to be sent in several batches and confirmation of transfer must be confirmed through the patient outbox.

If GP2GP is not available at the recipient practice, notes are converted to pdf and sent on memory stick with appropriate encryption. 

Ideally a .TIFF file should also be sent as this aids integration into most PMS.

For urgent notes transfer, where GP2GP is not available, notes may be sent as a letter via EDI to the recipient. As this leads to incomplete records transfer, a CD ROM should also be sent.

Where paper records or CD ROM based notes are to be mailed, a secure or tracked courier service should be employed. Records should not be sent by ordinary post.

The practice is not obliged to provide a paper copy of the records to another healthcare provider though it may be appropriate to send hard copy to those who find it difficult to cope with a .pdf file. Client continuity of care must be paramount.

Upon despatch of the records a note of the fact of the despatch including the destination, the courier used and any tracking number should be made in the client clinical record.

Confirmation of Receipt

When client notes are sent, the sending member of staff should set a task for the Practice Administrator or themselves to ensure that the sending has been followed-up.  Generally acknowledgement of receipt by GP2GP is sufficient.

When confirmation that client records have arrived at their remote destination is received, a note should be entered into the clinical records of the client.

Where confirmation has not been received within 5 days of despatch, a letter should be sent via email to the recipient requesting confirmation of receipt.

Where confirmation has not been received within 10 days of despatch, a phone call should be made to the recipient and an inquiry begun by the practice manager if the notes have not been received.

Receipt of Records

Generally, notes are received electronically.  These shall be imported using GP2GP where possible.

When received electronically, the clinical records shall be managed as with any other clinical data, and no special action is required.  Where possible a 30 minute appointment shall be made with new patients to ensure that there is time to review their records and bring them up to the practice expectations for record keeping.

Upon receipt of the records, the practice nurse shall ensure all recalls and immunisations that are due are actioned in a timely fashion.

Where notes are received on paper, they will be scanned into the clinical record excluding any test results over 10 years old or ACC flimsies.  Subsequently a clinician shall review the notes when time allows and ensure that any significant diagnoses are entered electronically.  After this, the paper records shall be destroyed in accordance with our health information privacy policy.

Update history:

23/07/2023 - removed facsimile as a transmission method.  Changed CD Rom to Memory Stick with encryption.

07/02/2016:

No Changes made

17/06/2014:

Minor wording changes

13/11/2012 GP2GP is the preferred method of transferring notes. Large files may need to be sent in several batches and confirmation of transfer must be confirmed through the patient outbox.

If GP2GP is not available at the recipient practice, notes are printed to pdf and sent on CD ROM