Such systems do not redact content.  They run an assessment tool and produce a shortlist of content for the user to review.  Each item has to be reviewed individually and a decision taken by the user.

As well as the proxy access article in this series, the Royal College of General Practitioners (RCGP) has published a guide to proxy access.

A record should be checked for sensitive information likely to cause serious harm and/or contains third-party information when:

Depending on when the information is added to a patient’s record will determine when, who and how the information is redacted.  A GP practice policy should be implemented, defining roles and responsibilities, including code lists, and how to redact information in the practice’s clinical system.

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Where the patient has previously and explicitly stated that information should not be shared with anyone or with a named individual, this must be adhered to.

If there are concerns relating to safeguarding and/or coercion, it may be appropriate for the practice to deny any level of access to a proxy.

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Peter confided in his GP that a named family member, since deceased, had been violent towards him on occasion. This had been noted in his clinical record.  When Peter became frail and confused sometime later, another family member, who was his designated proxy, requested access to Peter’s full, retrospective record.

As well as checking a record for sensitive and third-party information, you need to check for any sensitive or potentially harmful codes.  The software used to assess records for SARs includes these.

Redaction is the process of restricting access or ‘hiding’ information in the online viewer from the patient and anyone they have granted proxy access to.  It does not remove the information from the patient’s record.

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With the roll-out of live record access for patients, it is important to consider the need for redaction at the time information is entered or filed in the record.

Specific clinical system redaction guidance can be found in a series of NHS videos.  As the provision of clinical systems training and optimisation is a core and mandated requirement of the GPIT Operating Model, practices should contact their integrated care board, as the commissioner of the service, to request clinical system training, which is usually provided by the clinical system supplier or the local GPIT delivery partner.

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Most GP practices are familiar with redacting information from paper-based subject access requests (SARs).  The same principles and safeguards used for paper-based SARs apply to GP online records, except this is done by electronically tagging the information to be redacted.  The tags are then stored in the live clinical system they are entered in.

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After considering safeguarding issues, his GP redacted the reference to the violent family member to protect their identity, as Peter had not given explicit consent to this information being shared with any third party.

Individual words, sentences, or paragraphs within an entry cannot be redacted.  The entire entry, for instance the consultation or document  must be either shared (visible online) or redacted i.e. made not visible online).

What could be thought of as serious harm will vary from patient to patient.  Examples of content that might cause serious harm could include:

Most practices will already have access to a screening tool for producing SAR reports.  It has been shown that using a screening tool can reduce the time it takes to assess and redact an electronic record by up to 90%, which averages 2 minutes per record.

Where a patient has impaired competency, the practice has a duty of care to ensure that information which could be harmful to the patient is not shared with the proxy.

When GP records are shared with patients or their representatives (nominated proxy), the GP practice is responsible for ensuring that only appropriate information is disclosed.  To ensure this happens, information in both the existing record and any new items should be checked and where necessary, redacted.

Practices should assume that all patients (or their proxies) will eventually have real-time (prospective) access and ensure that the redaction tests of ‘serious harm’ and third-party information are applied by anyone entering information into the patient record.  This will save time in the long run.

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Sarah’s early onset dementia was progressing fast, and she agreed that her husband should have proxy access to her record before she became worse.  She’d had a termination of pregnancy when she was a college student and didn’t want her husband to know.  Her request was noted, and the record was redacted accordingly before access was given.

Most records will not have content that requires redaction.  For individual requests for full online record access (i.e. past, historic and current records) it is best practice for all of the record to be checked in advance of being shared.

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Before information is shared, sensitive information which could be harmful to a patient, or is about or references other people, should be assessed and a decision taken about whether or not it needs to be redacted.

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Each of the three main GP clinical systems handle redaction slightly differently.  It is important to ensure that you keep up to date with system functionality.

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Tools to help identify information in the digital record that may need to be redacted have been available for use in subject access requests for some time now.  These are either built into the clinical system or are third-party bolt-ons.

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Abnormal test results should not be automatically filed in a patient record.  They should only be filed once they have been assessed by a clinician.

While the patient or patient proxy cannot see the redacted information, it is still visible to clinicians and other authorised practice team members.

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Before enabling access to a proxy, the practice should alert the patient to any information in their record that may not be appropriate to share and if necessary to then redact that content.

The systems redact the entry from the patient view only.  Practice and any other authorised clinical users will still see this information when redactions have been made.  The patient will not know that content has been redacted.

It is not enough to say that disclosure would cause upset or stress to the individual.  Neither is it lawful to redact information that may protect a GP or other professional from criticism or challenge, or to hide an error or omission.

There are few hard and fast rules with redaction.  Information that may be fine to share with one patient, may need to be redacted for another.  Issues to consider are whether:

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A competent patient is able to allow a proxy (another individual, usually a family member or carer) to access their record.

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Before information is shared, sensitive information which could be harmful to a patient or is about or refers to other people (third parties) should be assessed, and a decision taken about whether or not to redact it.

You may also use other codes within your practice which you could consider sensitive, and these should also be included in a redaction review.

At the point information is being added to a patient record, whoever is entering or storing this information must consider whether it needs redacting.  Examples are:

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It is important to note that these tags may not transfer between clinical systems in the event of the patient record transferring between registered GP practices.

It may not be enough to redact only the name of the third-party if the associated content or its context would make it possible to identify the person.

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Full records access may require a review of historical (retrospective) information (paper-based and/or digital) and new approaches to entering and filing clinical information (prospective) information.

The definition of ‘serious harm’ is a matter for clinical judgement and will vary from patient to patient.  It may be considered as a significant shock or upset that could impair the emotional and mental well-being of the person receiving the information in the short to long term.  The shock or upset could result in them being emotionally, psychologically and/or mentally vulnerable or damaged.  It may even affect their ability to reason and rationalise and leave them feeling diminished and open to risk.

It is important that all clinicians and coders within the practice are trained how to redact information in a patient record and have access to the practice policy on maintenance of medical records and SARs.

For most patients there will be very little or no information in their record that needs redacting. They are likely to be fully aware of the information recorded and shared about them, including hospital letters, test results, and information which refers to other people such as family history or a family letter.

If the patient does not know about the information provided by or about another person, then this information must not be shared except with the agreement of the third party.

This guidance is part of the Information governance and data protection section of the Good practice guidelines for GP electronic patient records.

Currently not all GP IT systems can redact medications effectively, if there is a need to redact medication, check you are able to do so with your GP IT system supplier documentation.  This may be particularly important for contraception such as post-coital contraception.

Amina had been sexually active for some time prior to her marriage and had been to her GP regarding a termination of pregnancy prior to starting a relationship with her current husband.  She had a number of serious health issues and agreed with her GP it would be sensible for her new husband to have access to her record. She did not want him to see references to her previous Termination of pregnancy. Her record was redacted accordingly.