Civil Evidence Act 1995 and changing GP systems

Nicholas Bohm nbohm at ernest.net
Mon Aug 9 11:19:08 BST 2010


 On 09/08/2010 10:26, Peter Sommer wrote:
> The main purpose of the Civil Evidence Act 1995 was to admit hearsay
> evidence and to provide associated conditions.  Section 7 made it
> possible to admit copies of documents and section 8 allowed for the
> admission of "records" of a business or public authority provided
> there was an affidavit / certificate that the records formed part of
> the regular business activity.
>
> Thus,  the law is about allowing such records to be admitted (whereas
> before much more complicated forms of proof were required).   Once the
> evidence is admitted it is still open to challenge on the grounds of
> weight (eg that in some respect it is not accurate).  However normally
> there will be a rebuttable presumtion in favour of reliablity.   
>
> The Civil Evidence Act does not prescribe standards by which records
> in electronic form  should be kept.   There are some applicable
> international standards:  ISO 18492:2005 and 15801:2009.  There are
> also some BSI documents:  BS 10008:2008.
>
> I don't know if elsewhere there are specific requirements for the
> maintenance of medical records.
>
> Off the top of my head,  I would guess that the obligation would be to
> keep old records in their original electronic format plus the software
> necessary to read them.  And probably have more than one copy kept in
> more than one place for safety's sake.   An audit trail in the form of
> a document saying when the archive was created and by whom would also
> seem to be a good plan.
>
> Unless some-one else here knows better? 

I don't know better; but I don't think it's a matter of obligation so
much as incentivised by self-interest. 

The law, as Peter says, is about admissibility of what is there.  Apart
from tax-related obligations to keep some records, a GP practice that
wants to be able to defend itself against clinical negligence claims
needs to have its old records available, admissible and reliable. 
Compliance with standards must be a help.

The ISO and BSI standards are probably elaborate, but I suspect they
come down to very much what Peter describes.

Nicholas
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