All patient records used in remote visits will need to be anonymised. You should present an anonymised patient record in the same way you would present a patient record at a face-to-face visit.
There is no requirement to anonymise records that are shown to your assessor during a face-to-face visit, even if a competency with anonymous patient record as compulsory evidence has been carried forward from visit two.
How to anonymise and present your records
You must not alter the patient record in any way, beyond anonymising. Changes to patient records are considered a form of cheating.
In your place of work, remove:
- the patient name
- address
- date of birth
- GP details
- telephone number
- any other patient identifiable details from the record.
You need to duplicate the record before anonymising. You can either redact records electronically or cross the details out with black ink so that details cannot be seen.
You must do this while in your place of work. You must never take patient records with identifiable features out of your work premises.
You can record the age and ethnicity of the patient on the record if it is clinically significant.
Once a record has been anonymised, store it electronically so that you can screen share it during your visit.
Your supervisor must then sign a separate declaration confirming that your anonymised patient records have been checked, and appropriately anonymised.
Be prepared to share the record on screen with your assessor during your visit. The record must be clearly visible to the assessor.
The anonymised record should not be sent to the assessor ahead of a visit, or ever held by the assessor.
You must keep a record of the actual patient record from which each anonymised patient record is taken, in case your assessor needs to cross-check it.
Record checking
At visit three, your assessor will check a minimum of three, and not normally more than ten records across the categories of anonymised patient records, reflective accounts and trainee-led case discussions that you used at visits one and two.