GPs often receive requests from lawyers and other third parties for information on or a comprehensive record of a specific patient. As such, GPs may be obliged to disclose patient health information in certain circumstances and requested to do so in others. Providing records to facilitate resolution of legal disputes is usually in the interest of patients (unless the patient has claimed things that are untrue) and in the public interest.
This document is a guide for general practices to advise which data elements should be extracted from a patient’s electronic medical record when responding to external requests for their record. This document is for use once the decision has been made to provide a third party a copy of (or part of) a patient’s medical record.
It is recommended that data sets developed by the OPTIMUS group be adopted by medical software vendors for integration into their systems to ensure the safe and accurate extraction of a patient’s comprehensive medical record.