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Good practice guidelines on completion of GP reports from the Joint GP IT Committee

September 2004

For some time now, many practices have been using software produced by their suppliers to extract a draft insurance report from the medical record, which they then print, edit and post back to the insurers. Using the same method for extracting the draft report, eGPR uses automation in the request, despatch and payment parts of the process.

Like any other healthcare intervention, eGPR can only be safe and effective if it is used responsibly and appropriately.

For this reason, it is essential that practices and practitioners:

• Are familiar with the ethical as well as the practical requirements for GPRs
• Are aware of the sources of information from which to refresh this knowledge when needed
• Familiarise themselves with the eGPR process before using it 'for real'
• Have read and do observe the Good Practice Guidelines (GPG) for GPRs

• GPs should be aware that they have the option to decline to complete a GPR in any form.
• The responsibility for ensuring the appropriateness, correctness and completeness of a GP report remains as firmly with the GP as if he/she had hand-written the whole of it personally.
• In fulfilling this responsibility, GPs must be aware of the fundamental difference between electronic and paper GPRs. A paper GPR is an empty document that the GP populates by adding data to it. The electronic GPR is automatically loaded with data by the GP's computer system and the GP then has to take out (i.e. edit) any information that need not or should not be included:
• Negative HIV, Hepatitis B or Hepatitis C test results;
• Instances of sexually transmitted disease without long term health implications;
• Genetic test results which are unfavourable for the patient;
• Information about third parties which was not supplied by the patient.
• The patient's consent for release of the information must be confirmed in every case.
• Each draft report needs to be scrutinised and edited where necessary by the responsible GP.
• When GPs are editing a report to remove inappropriate material, they should be aware that the same information may appear in more than one place in the medical record, and therefore also in the extract that forms the draft report (e.g. in problem list and in consultation record(s).
• Practices should keep a copy of the report which is submitted to the insurer (i.e. the last version after any editing) together with a record of who was responsible for it and when it was sent. An outline of suitable storage formats (such as TIFF) can be found in Section 6.4 of the RCGP/GPC's Guidelines for General Practice Electronic Patient Records.
• The obligation to observe the 21 day rule remains, regardless of the form of the report.

• The eGPR service should be treated solely as a mechanism for swiftly despatching a completed report, and not as a further opportunity for editing it.