Working well in organisations and systems for MRCGP AKT

A patient asks your practice for a copy of their full medical record under UK GDPR. What is the correct response?

1. Provide the record within 40 days on payment of a £50 administrative fee Wrong. That is the old Data Protection Act 1998 position, replaced in 2018.
2. Release only entries the GP considers clinically appropriate to share Wrong as a general rule. Withholding is permitted only for serious harm to the patient or another person, or third-party identifying information, and each withheld item must be justified.
3. Require the patient to give a reason for the request before releasing anything Wrong. A data subject does not have to justify a subject access request.
4. Refer the request to the Information Commissioner's Office for approval Wrong. The practice is the data controller and answers the request itself.
5. Provide the record free of charge, normally within one month of the request correct Correct. A subject access request must be answered without undue delay and within one month, extendable by two further months for complex or numerous requests. No fee applies unless the request is manifestly unfounded or excessive.

The point: Subject access request: one month, free, no reason required, extendable to three months if complex. Redact third-party identifying information and the narrow serious-harm exemption, documenting why for each redaction.

Source: ICO — Right of access Information Commissioner's Office · tier 1, national regulator or guidance

A 38-year-old man attends requesting a sick note. He has been off work with back pain for 5 days and has not been seen by anyone yet. What is the correct position?

1. Only a hospital doctor can issue the first fit note Wrong. Fit notes can be issued by a range of healthcare professionals including GPs, nurses, pharmacists, occupational therapists and physiotherapists.
2. A fit note is required from day 4 of absence Wrong. Day four is not a threshold in the self-certification rules.
3. The employer must apply directly to the practice for the certificate Wrong. The fit note is given to the patient, who provides it to their employer. The practice does not correspond with the employer without consent.
4. A fit note is required from the first day of absence Wrong. Requiring one from day one creates unnecessary appointments and is not the legal position.
5. No fit note is needed yet; employees may self-certify for the first 7 calendar days correct Correct. Self-certification covers the first seven calendar days of sickness absence, including non-working days. A fit note is required only from day eight.

The point: Self-certification covers the first seven calendar days. Fit notes can be issued by several professions, can say 'may be fit for work' with adjustments, and are advice to the employer rather than a binding instruction.

Source: DWP — Getting the most out of the fit note: guidance for healthcare professionals UK Health Security Agency · tier 1, national regulator or guidance