Civil Evidence Act 1995 and changing GP systems
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.
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