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Medical Reports

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As of 29th Jan 2024 please see 💸New Medical Report Fees for the new fees

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Contents:

Introduction
Procedure
1️⃣ Receiving the request
Online - via website
In-person
2️⃣ Assessing the request
3️⃣ Contacting the requester
4️⃣ Invoicing
5️⃣ Preparing for Review
6️⃣ Reviewing the report
7️⃣ Dispatch

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Summary: This protocol shows you how to process requests for medical reports / records, including assessing appropriateness of requests, invoicing and completing requests

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Who’s it for: Medical Reports team

Introduction

The Practice has a primary duty to provide services for the management of patients who are ill. Writing letters and reports (i.e. for insurance providers, adoption and fostering, driving (DVLA), housing and benefit appeals, schools, health clubs and employers) all fall outside of the NHS GP contract.

Either the patient or a third party pays a fee towards the practice’s time and admin costs. Medical reports are dealt with by the Medical Reports Team.

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There are some exceptions, such as for 📁Subject Access Requests (SAR) & which are free, as well as some benefits reports

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Any communication with the patient (i.e. emails, invoices) and drafts of the report must be recorded on patient's EMIS record. All entries should be hidden from patient's view.

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How to restrict visibility of a document

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When and how to share information

Procedure

1️⃣ Receiving the request

Online - via website

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Medical Reports Coordinator

The patient completing the form themselves online is the preferred route
All online forms, and forms completed on patient’s behalf by reception will arrive in the generic site inbox

In-person

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Reception

For patients who come in to surgery to request a report, fill in the online form for them
Ensure physical letters are passed to Clinical Admin for scanning
For more info please see 📜Handling Medical Reports Requests

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On-site Clinical Admin Team

Ensure physical letters are scanned, using the scan2email function:

Scan2email Instructions1040.7KB

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If this is a 📁Subject Access Requests (SAR) or ensure those processes are followed

2️⃣ Assessing the request

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Medical Reports - Coordinator

Checklist - Work through the ‘triage’ checklist on the Asana task
Appropriate - Is the request something we usually do?

We don’t process housing application support letters
On some occasions it may be quicker and easier to give patients a copy / printout of their notes (which is free of charge)
Patients can also access their notes via 💜Patient Access & the NHS App

Consent - check if we have the appropriate consent to disclose information, and has the patient requested to see the report before it’s dispatched to 3rd party

In some cases we do not need to seek the patient’s consent (e.g. if the police are requesting information - see more information here)
This information should also be recorded in Asana
If the requestor doesn’t have patient consent, escalate this to the clinical admin lead

Medical history - check if we have the patient’s full medical notes or the information to fulfill the request

If there is any information that we don’t have on the system, for example if a patient was seen somewhere privately, they must send a copy of this to us or we can’t complete their request
If the patient is new to our practice, we may be unable to process the request until we receive a full set of notes from their previous GP surgery
If we have enough information to produce a useful report but are missing some details, include a note in the report stating this limitation

Fees - Refer to 💸New Medical Report Fees
Processing time - check what our current wait time for reports is, and if there are any aspects of the request that may alter processing time

If a specific clinician needs to work on a report, this may change the processing time depending on the clinician’s availability
If a patient needs an appointment before the report can be completed, this needs to be noted before contacting the requester

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This step is for evaluation only - we don’t start working on the request until payment is received

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Yellow fever vaccination exemption requests must be passed to Reception to book a consultation with a trained yellow fever vaccinator

3️⃣ Contacting the requester

Contact the person requesting the medical report by email with the following information:

Confirm the appropriate level of consent
Explain how the process works and what we will be able to cover in the report
Explain that there is a charge for their request and quote the fee (💸New Medical Report Fees)
Provide information on processing time and tell the requester that we won’t start work on their request until payment is received
Give your name and the practice generic email address (not personal) in case the patient wants to contact us
See 📝Payment Templates for templates
Update asana detailing what was discussed

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Log details of contact (email or any verbal communications) in patient’s EMIS records and restrict visibility of the entry.

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If we do not have an email address on record, call the patient and add this to their records

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If the patient is not willing to pay, speak to the Clinical Admin Lead. We may be able to give an extract of medical information from their EMIS records instead.

4️⃣ Invoicing

Once you have contacted the requester (as above) and established the fee for their request, you need to send an invoice. By default we send invoices by email, but can also send them by post if this is specifically requested.

All invoices should be created using our payment platform service, Stripe. See 🦮Guide for Stripe Invoicing for more.

Ensure invoices are added to the patient’s EMIS record, and visibility restricted.

Our primary method of payment is bank transfer, but can offer card payments if there are issues with this.

Always ask requestor to send proof of payment when they have made the payment. This will enable you to track the payment and start working on their request as soon as payment is received. Proof of payment can be a screenshot of the bank transfer.

Update Asana with details of invoice issued, and again when payment received.

Our VAT number is: 450 240 438 - add this to all invoices that require it

5️⃣ Preparing for Review

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Medical Reports - Underwriter

Once payment is received:

The underwriter will assemble the requested report

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Double check what the request is actually for, and thoroughly check active issues, consultations, and history to make sure that you’re including all relevant information. You may not need to include third party data e.g. previous medical reports, referrals, sick notes, registration forms if its not mentioned in the request and in consent.

6️⃣ Reviewing the report

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The GP will review the report through EMIS, and respond via task when the report has been reviewed. (For more see 📜Reviewing Medical Reports)

7️⃣ Dispatch

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Medical Reports - Underwriter

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You must check consent before sending or printing the report

Once the GP responds:

Make any changes to the report, and add the GP’s signature to the report
Contact the requester to tell them it is completed, and email a copy of the request to them if they have asked to see the report before it is sent to the 3rd party
Update Asana
Upload the completed report to EMIS

Coordinator:

Send the report to the patient by email, or by post if the report came with a prepaid envelope or if the patient requests a printed copy

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Resources:

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Subpages