Letter: Is this a record? - not according to the NHS

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Sir: Paper records can easily be hidden or lost.

Many GPs, like myself, prefer to keep records as computer files, and all recognised GP clinical software (Surgery Manager, Meditel, EMIS for instance) has for many years retained an audit trail of all alterations to the record, allowing a claim that a record has been expunged to be investigated (and, from the GP's point of view, defended).

However, the Department of Health has for several years dragged its feet over the simple change to the rules from a requirement that doctors keep "records on the forms provided", to "keep suitable records". The result is that GPs keeping excellent records may be found technically in breach of their conditions of service, and have little protection against arbitrary and potentially large fines.

A parliamentary select committee reported that they expected these minimal changes to be introduced very soon; that was very long ago and among all the other left-over undone jobs in the NHS, the current government should find five minutes to alter that sentence.


Chairman Exeter Division of the British Medical Association