Guidance and information for secondary, community and mental health service staff

This will include information sent into general practice from secondary care and other providers to be added into the patient record, such as outpatient clinic letters, discharge summaries and other correspondence. 

• In exceptional circumstances, general practice can redact whole items that should not be disclosed, including “where the disclosure of or access to the information is likely to cause serious harm to the physical or mental health of the individual or another person”.
• If a clinician writing a letter feels a specific piece of correspondence meets this threshold, they should mark the letter clearly and prominently in this way for example “not for disclosure to patient”. It is not possible to redact parts of letters or other correspondence, only the whole item can be redacted. 
• Similarly, if the clinician believes the patient cannot keep their online access to records secure, or the patient expresses concern about being able to view their records online, then the clinician should inform general practice to not disclose the letter and to consider reviewing any access that is being provided.
• Sensitive test results – if you do not wish your patient to view results or diagnosis that you have carried out until you have had the opportunity to speak to them in person, please either wait until you have spoken to the patient or mark your correspondence clearly and prominently that it is not for disclosure to the patient.
• Abnormal test results requiring no action – whilst no action may be required from a clinical point of view, seeing ‘abnormal’ results may cause distress to the patients. Therefore, please include an appropriate explanation that the patient will understand.
• Safeguarding or third-party information – if a communication being sent to general practice risks causing harm if viewed by the patient, please make this known to primary care colleagues by marking clearly and prominently for example not for disclosure to patient, stating the reason why.
• Language and medical terminology please be aware that your communication could be read by your patient, so it is recommended that every care is taken to record clinical correspondence in a way that both conveys the necessary detail to other professionals and considers the impact of receiving such a letter for patients.
• Access to GP records does not replace the current practice of communicating and sending letters directly to patients, staff should continue to follow their local processes.
• Some services do not automatically send correspondence to general practice except when the patient has consented to do so (for example sexual health or HIV clinics). In cases where there is consent, health professionals should inform patients that it will automatically be available to view by the patient as part of the general practice record.