Reading List

A curated Reading List to support and extend learning from Recording Reception Notes and Patient Contact Accurately.

These sources cover accurate records, data protection, confidentiality, online record access and safeguarding-sensitive information in general practice.

1. Records and Record-Keeping

• NHS England - Records Management Code of Practice
  NHS guidance on how health and care records should be managed, retained and handled.
  https://transform.england.nhs.uk/information-governance/guidance/records-management-code/

• NHS England - High quality patient records
  Guidance on the clarity, accuracy, completeness and usefulness of GP electronic patient records for direct care.
  https://www.england.nhs.uk/long-read/high-quality-patient-records/

• NHS England - Consent to using and sharing patient information
  Explains that recording information about individual patients does not generally require consent and sets out the duty to keep clear, accurate records.
  https://www.england.nhs.uk/long-read/consent-to-using-and-sharing-patient-information/

2. Data Protection and Confidentiality

• ICO - Accuracy principle
  ICO guidance on keeping personal data accurate, recording source and status, and correcting errors where needed.
  https://ico.org.uk/for-organisations/uk-gdpr-guidance-and-resources/data-protection-principles/a-guide-to-the-data-protection-principles/accuracy/

• ICO - A guide to the data protection principles
  Overview of the UK GDPR principles, including accuracy, data minimisation, security and accountability.
  https://ico.org.uk/for-organisations/uk-gdpr-guidance-and-resources/data-protection-principles/a-guide-to-the-data-protection-principles/

• GOV.UK - The Caldicott Principles
  Principles for protecting and sharing confidential patient information, including the duty to share when needed for individual care.
  https://www.gov.uk/government/publications/the-caldicott-principles

3. Online Records and Safeguarding

• NHS England - Online access to new GP health record information
  Guidance on patient access to new GP record entries and the implications for practice processes.
  https://www.england.nhs.uk/long-read/online-access-to-new-gp-health-record-information/

• NHS England - Safeguarding in GP electronic patient records
  Guidance on recording safeguarding information in GP electronic records, including risks around online access and redaction.
  https://www.england.nhs.uk/long-read/safeguarding/

• NHS App - Safeguarding patients from harm or distress
  NHS Digital guidance on protecting patients who may be harmed or distressed by access to online health record information.
  https://digital.nhs.uk/services/nhs-app/clinical-safety-and-safeguarding/safeguarding-patients-from-harm-or-distress