Dealing with medical records for adopted patients: An NHSE guide for GP practices

Current adoption legislation requires that all adopted patients are given a new NHS number, and that all previous medical information relating to the patient is put into a newly created medical record. Any information relating to the identity or whereabouts of the birth parents should not be included in the new record.

Whilst changing or omitting information from medical records would usually be contrary to ethical and professional guidance, this is not the case for the records of adopted patient and there is a legal requirement that it takes place.

If the patient is staying registered with your practice:

• Primary Care Support England (PCSE) will send through a deduction for the patient on your clinical system and emails the main contact held for GP practice (if available) with new NHS number and any other amended details for the patient
• Accept the deduction and register the patient with their new NHS number and any other amended details. Important: It is not possible to update the patient’s original record with their new NHS number. If this happens they will not be registered and will miss out on continuity of care
• Following the registration, new medical record envelope will be sent to you, with the patient’s new NHS number and other post-adoptive details. The original notes can then be placed in the new envelope.
• You should not make any changes that conceal or alter the patient’s clinical history, however, steps should be taken to prevent disclosure of their pre-adoptive identity - for example blocking out all references to the previous name and any information that may identify members of the birth family.
• The pre-adoptive identity must be regarded as confidential and practices must ensure that they have robust systems in place to manage disclosure and/or access.
• If possible, electronic medical records should be merged on the GP practice system with the new post-adoptive details. Please ask your system supplier for guidance on how to do this.

If the patient is moving area and registering with a new practice:

• The medical record will be requested from you in the normal way.
• You may also be contacted with a request for a summary of the medical history etc., in which case the above guidelines should be followed regarding prevention of the patient’s pre-adoptive identity.The pre-adoptive identity must be regarded as confidential.