Until recently general practitioners were wary of using only
electronic records because of the risk of the record not being able to be
allowed in court in event of a dispute. Terms and conditions of service
for general practitioners state that records have to be kept on the forms
provided by the Secretary of State.
This part of the GP contract is now
outdated and should be urgently replaced. As electronic records have
become more sophisticated, worries about acceptance of records in court
has become less of a problem. All GP computer systems that are compliant
with the latest requirements for accreditation (RFA4) have an audit trail
built into them. This allows recording of who altered a record and when it
was altered. Although such audit trails are now integral with the
software, even systems that did not have them specifically designed in
have been used in court. Two cases are of importance.
In 1995 a doctor in
South Wales was found guilty of altering patient records on his computer
and jailed. He had accidentally prescribed a b-blocker to a patient with a
history of asthma resulting in the patient's death. He attempted to remove
electronic references to asthma treatment on his computer system but the
alterations were detected and he was convicted.
In a more recent case, Dr
Harold Shipman altered the computer records of his patients after their
deaths to fit with the cause of death that he had put on the death
certificate . The way that the Microdoc system that he used recorded the
information enabled the prosecution to demonstrate that some records had
been added months after they were meant to have been. Their position in
the database was incompatible with the date attached to them.
These two
cases and current audit trails should enable doctors, or lawyers acting on
behalf of litigious patients, to use electronic medical records from
British general practice in future court cases. The requirements of the
Terms of Service to use paper records should thus be abandoned.
1 National Health Service (General Medical Services) Regulations
1992 SI 1992 No. 635 Para 36 A
2 Doctor accused of killing patients (News Item) BMJ 319:1026 16
October 1999
Dr Trefor Roscoe
Informatics Tutor - North Trent
Institute of General Practice
Sheffield University Medical School
Rapid Response:
Legality Of Electronic Records
Until recently general practitioners were wary of using only
electronic records because of the risk of the record not being able to be
allowed in court in event of a dispute. Terms and conditions of service
for general practitioners state that records have to be kept on the forms
provided by the Secretary of State.
This part of the GP contract is now
outdated and should be urgently replaced. As electronic records have
become more sophisticated, worries about acceptance of records in court
has become less of a problem. All GP computer systems that are compliant
with the latest requirements for accreditation (RFA4) have an audit trail
built into them. This allows recording of who altered a record and when it
was altered. Although such audit trails are now integral with the
software, even systems that did not have them specifically designed in
have been used in court. Two cases are of importance.
In 1995 a doctor in
South Wales was found guilty of altering patient records on his computer
and jailed. He had accidentally prescribed a b-blocker to a patient with a
history of asthma resulting in the patient's death. He attempted to remove
electronic references to asthma treatment on his computer system but the
alterations were detected and he was convicted.
In a more recent case, Dr
Harold Shipman altered the computer records of his patients after their
deaths to fit with the cause of death that he had put on the death
certificate . The way that the Microdoc system that he used recorded the
information enabled the prosecution to demonstrate that some records had
been added months after they were meant to have been. Their position in
the database was incompatible with the date attached to them.
These two
cases and current audit trails should enable doctors, or lawyers acting on
behalf of litigious patients, to use electronic medical records from
British general practice in future court cases. The requirements of the
Terms of Service to use paper records should thus be abandoned.
1 National Health Service (General Medical Services) Regulations
1992 SI 1992 No. 635 Para 36 A
2 Doctor accused of killing patients (News Item) BMJ 319:1026 16
October 1999
Dr Trefor Roscoe
Informatics Tutor - North Trent
Institute of General Practice
Sheffield University Medical School
Competing interests: No competing interests