Detailed Coded Record (DCR) Access

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Overview

The 2014/15 GP Contract’s contractual obligations for Patient On-line Access were to allow patients the ability to:

• book/cancel appointments
• order repeat prescriptions
• view a summary their care record (allergies, adverse reactions and medications)

The 2015/16 GP Contract has added to this the requirement that Practices must also allow patients to:

• have access to their Detailed Coded Record (DCR)

The Detailed Coded Record gives the patient on-line access to their problems, medications, laboratory test results, documents, allergies, consultations and immunisations.

Patients accessing their records on-line will have access to a limited level of information. As a result of this the patient continues to have the right to submit a Subject Access Request under the Data Protection Act 19983, which must be submitted in writing to the Health Centre; the Health Centre still has the right to charge a fee for providing this information in printed form.

Application for DCR Access

The Health Centre will accept an application for access to a DCR from a patient or their proxy. Proxy access refers to access to the DCR by somebody acting on behalf of the patient and with the patient’s consent. The appropriate application form must be completed prior to access to the DCR being enabled:

• Appendix A, Consent for Patient Access to their Detailed Coded Record (DCR), should be used by patients wanting to access their own DCR. Complete our secure online form
• Appendix B, Consent for Proxy Access to a Detailed Coded Record (DCR), should be used for individuals requesting access to a patient’s DCR, providing of course they have the patient’s consent to do this or are authorised to do so e.g. as a parent/guardian/carer of a child under 11 years of age or via a Personal Welfare Lasting Power of Attorney (LPA) for an adult. Complete or secure online form

The Health Centre reserves the right to deny access to the DCR, or to remove access to the DCR in the future, if it is thought that this would be in the best interest of the patient or if the access is suspected of being misused.

Identity Verification

We will need to verify your identity to ensure that access to your DCR is only granted to patients/proxy users that have a legitimate reason to access it.

For existing patients this identity verification may be possible by the Receptionist who receives your completed application form, providing you are known to them.

If we do need to verify your identity you will need to provide two forms of documentation as evidence, one of which must contain a photograph. Acceptable documents include passports, photo driving licences and bank statements. If these cannot be provided then household bills may be accepted at the discretion of the Business Manager.

Timescale

Please be advised that it may take the Health Centre up to 10 working days to review your application and to then grant access if approved. This is a however only a guide and in some circumstances the process may take longer.

Considerations/Approval of Access

Your care record will be checked by trained members of staff within the Health Centre who will consult with your Usual GP if required in line with the following considerations:

• Potential physical or mental harm: The Health Centre will not approve on-line access to the DCR if it is deemed that such access may cause physical and/or mental harm to the patient.
• Mental health problems and/or learning difficulties: Patients with a mental illness or learning difficulties have as much right as any patient to have on-line access to their records, however if there is a likelihood that such access may cause them physical or mental harm then it may be necessary to:

1. redact some of the information within the record, or…
2. refuse access to the whole record

• Access to a child’s DCR by their parent/guardian/carer: The on-line DCR of a child under the age of 11 may be accessed by their parent/guardian/carer as a Proxy user. A child aged 11-16 years and deemed as competent may have their own access to their on-line DCR or alternatively may authorise their parent/guardian/carer to have access to their on-line DCR as a Proxy user. Where a child aged 11-16 years is deemed not to be competent, a parent/ guardian/carer may apply for access to their on-line DCR as a Proxy user.
• Proxy access: A competent patient can choose and consent to allow access to their DCR by relatives and/or carers by submitting the form in Appendix B, Consent for Proxy Access to a Detailed Coded Record (DCR). Circumstances when the Health Centre will consider authorising Proxy access to a patient’s on-line DCR without the patient’s specific consent will be for the parent/guardian/carer of a child under 11 years of age or for a relative/carer of an adult with a Personal Welfare LPA.
• Coercion: Coercion is the act of governing the actions of another by force or by threat, in order to overwhelm and compel that individual to act against their will. The Health Centre will be vigilant for any signs of coercion of the patient when they apply for access to their on-line DCR and will decline the application should coercion be deemed as taking place.
• Sensitive information in consultations: Sensitive information discussed in consultations e.g. domestic abuse is not routinely marked as confidential and will, therefore, be visible on-line.