§ Mr. GroganTo ask the Secretary of State for Health if he will make a statement on the Government's policy concerning the addition to medical records of material received from third parties without medical qualifications. [128136]
§ Ms Rosie WintertonThe Department of Health does not publish guidelines on what should be recorded in a patient's medical record; the judgment of what is relevant is left to the responsible health care professionals. However, the General Medical Council (GMC) in its 'Good Practice' guidance provides general advice on the use and content of medical records.
At present the patient's total national health service medical record consists of a series of paper sub-records divided according to the organisations where the patient has received health care. This means that a patient could have a record for each hospital and other health organisation he/she has attended as well as a general practitioner record. The health care professionals of each organisation are responsible for compiling and maintaining the medical records.
Should the patient's health care professional judge that some information, from whatever source, could make a contribution to the patient's health care, then it would be appropriate for it to be included in the patient's medical record. The fact the information is contained in the medical record is accepted as having been vetted by health care professionals and relevant to 209W the patient's health and care. The patient cannot at present ask for information from an external source to be added to the medical record.
Work currently being taken forward by the national programme for information technology will provide an electronic summary record for each patient in England. This record will either hold or provide access to the key information provided by all NHS organisations involved in the patient's care.
A section of this record will be under the patient's control. They will be able to add comments, including information from third parties (with or without medical qualification), to their records to ensure those records will contain the views and information that they wish to have, in addition to the normal information provided by the NHS.