2.3 New patient's records

2.3 Newly enrolled patient records

Patients and practices need assurance that any hard copy health information transferred between providers reaches the intended recipient. Information management to track health records may be in an electronic or hard copy format. Electronic tracking may be done by checking the PMS to confirm the electronic file has been successfully sent, and documenting this in a transfer out logbook.

Standard – what we’ll be assessing on Evidence to provide for assessment

2.3 The practice ensures newly enrolled patients records are reviewed by a clinician.

  • A documented records transfer policy and procedure for patient records in and out of the practice, including timeframes. 

The internal tracking of a new patient’s medical file may involve a combination of electronic and hard copy notes. Each team member has a role in this process and it is important the practice has a process whereby the notes are correctly assigned to a GP and triaged for any recalls or critical follow-ups that are due.

Examples of tracking the receipt of health records by another authorised agency may include the inclusion of a fax-back form, the use of registered mail or courier packs with a signature required to authorise release and confirm receipt. The transfer of hardcopy notes between practices needs to be with track and trace services such as courier. The use of standard postal services is not considered secure.

Using an electronic system to transfer records

A system like GP2GP, which has the capability to transfer a patient’s files electronically from one general practice system to another, allows the transfer of records reliably, securely and accurately.

Records transfer policy

Records Transfer Policy and Procedure must include:

  • How the practice manages the transfer of clinical records in and out of the practice.
  • The method for tracking hard copy health records, for example, hard copy transfers use track and trace services such as courier.
  • The method for confirming electronic records have been sent/acknowledged.
  • Timelines for transfers ‘out’ of patients’ medical notes which adhere to legislation (20 days legally but 10 days is recommended by RNZCGP).
  • A process for the efficient managing of new patients’ medical information.
  • Roles and responsibilities of key practice team members processing the medical notes internally.
  • Timelines for the processing of medical notes internally.