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Nigel's surgery 12: Accessing medical records during inspections

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  • Organisations we regulate

We review medical records when we inspect GP and urgent care services. This is to assess the quality of care provided by the practice. It is not to assess the individual clinician.

CQC's powers to access medical records

We have powers under the Health and Social Care Act 2008 (the 2008 Act) to access medical records to exercise our functions. We balance these powers with responsibilities under the:

  • Data Protection Act 2018
  • Human Rights Act 1998
  • common law duty of confidentiality.

We respect and protect the privacy and dignity of patients and maintain confidentiality of their records.

Our Code of Practice on Accessing Confidential and Personal Information describes our powers to access medical records. We will look at a patient's medical records where:

  • it is necessary, and
  • intruding on that patient’s privacy is justified and proportionate.

This code outlines the necessity test we must meet before we access confidential and personal information whilst exercising our powers.

Our inspection teams will always follow the code when they access medical records during inspections of NHS GP practices and GP out-of-hours services.

National data opt-out

National data opt-out seeks to give patients and the public more control over how their confidential patient information is used for research and planning. It follows

The opt-out does not apply to our access to records. If a provider tells us that a patient does not want us to look at their records, we will respect this unless there is an overriding need to look at that particular record.

When we inspect

Why we look at medical records

We assess the quality of care and corroborate this through the evidence we see in medical records. This includes nursing records. We look at medical records to assess the quality of care provided against our key lines of enquiry (KLOE) We look at this evidence alongside:

  • other evidence gathered on the inspection
  • information we have from our ongoing relationship management with the provider
  • information from CQC Insight
  • information gathered before the inspection

We do not assess an individual clinician's ability. If we identify particular concerns about an individual clinician we will refer them to the appropriate body, for example GMC or NMC.

What records will we review?

The types of records we may need to review to answer specific KLOEs.

KLOEs

S3.1 Are people's individual care records, including clinical data, written and managed in a way that keeps people safe?

S4.2 Are medicines appropriately prescribed, administered and/or supplied to people in line with the relevant legislation, current national guidance or best available evidence?

E1.7 Are people told when they need to seek further help and advised what to do if their condition deteriorates?

Examples of records

A sample of consultation records for a range of clinicians to check:

  • notes are contemporaneous
  • contain enough information (including clinical findings, decisions made and actions agreed)
  • medicines are appropriately prescribed

(The sample should include records related to acute presentations and managing patients with long term conditions)

The safeguarding register and a sample of patients on the register


KLOE

S3.2 Is all the information needed to deliver safe care and treatment available to relevant staff in a timely and accessible way? (This may include test and imaging results, care and risk assessments, care plans and case notes.)

Examples of records

Systems for:

  • processing test results
  • hospital correspondence
  • out-of-hours / A&E attendances
  • safeguarding alerts

Make sure:

  • problems lists and summaries are accurate
  • there is a past medical history with allergy status recorded and medications listed.

KLOE

S4.6 Are people receiving appropriate therapeutic drug and physical health monitoring with appropriate follow-up in accordance with current national guidance or evidence?

Examples of records

Search the clinical system to identify patients prescribed high risk medicines

Review a sample of patients to make sure they are receiving:

  • appropriate monitoring (and medicines are not prescribed when monitoring is overdue)
  • advice about their medicines
  • safety netting is in line with guidance

KLOE

S6.5 How effective are the arrangements to respond to relevant external safety alerts, recalls, inquiries, investigations or reviews?

Examples of records

Search the clinical system to:

  • identify patients affected by patient safety alerts/alerts from the Medicines and Healthcare Products Regulatory Agency (MHRA)
  • review sample of records to make sure action has been taken

KLOE

E1.1 Are people's physical, mental health and social needs holistically assessed, and is their care, treatment and support delivered in line with legislation, standards and evidence-based guidance, including NICE and other expert professional bodies, to achieve effective outcomes?

Examples of records

  • a sample of individual care records for specific groups of patients eg. patients with a mental health condition, frail older people, children with long term conditions
  • the carers register

Process for looking at medical records

  • A clinician on the inspection team would usually review of information on the clinical system. This may be the GP or the practice nurse specialist advisor on the team. We feel it is appropriate for clinicians to lead this aspect of the inspection where possible, although the 2008 Act does not require this.
  • How many records we look at depends on the evidence we see in the practice and within the medical records.
  • Our powers allow inspection teams to access people's records without their consent. So there is no requirement to seek consent from people
  • Practices can anonymise records. Our inspection teams will decide with the practice, whether it is proportionate to do so. Some practice systems can anonymise records easily but this can be done manually. However, it is the inspection team who decide which records are viewed.
Last updated:
22 August 2019

 


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