Working with online record access - the challenges

Potentially harmful data

GP records sometimes contain confidential information that relates third party which the patient must not see. There may also be information that may harm the patient: a diagnosis, abnormal result or opinion that the patient is not aware of or records of a past traumatic event that might re-traumatise the patient.There may be information that a patient who is coerced to share their online record access may want to have redacted.

As a principle it is helpful to consider “Ask before release”, which means if you are uncertain whether information you are entering in the patient’s record may be something the patient would prefer not to be visible online, ask the patient if it should be redacted.

All GP systems have a method of preventing information in the record being visible via GP online services. This is redaction. Before online access to historic records is switched on all the information that the patient will see should be checked for potentially harmful information that needs to be redacted. 

It is important to establish a practice record keeping policy about recording and redacting new entries of potentially harmful and confidential third party data even if patients do not currently have online record access, as they may gain access in the future.