THE MEDICAL RECORD
Your medical record is held with the GP Practice with which you are registered. It contains general information about you, including your name, address, date of birth and details about the clinical care you have received throughout your lifetime. This record has been built up between yourself and your doctor. Your GP is responsible for the accuracy and safe keeping of your medical record. If you move to another area or change your GP, your medical records are sent to your new practice. The NHS Central Register for England & Wales only contains basic personal details of all patients registered with a GP, the register does not contain clinical information.
HOW IS YOUR MEDICAL RECORD STORED
It is important that you know your personal data is protected, as your medical records are increasingly stored electronically on computers. The practice uses a remote hosted system called EMIS Web. All patient data is encrypted and sent electronically over the secure NHS N3 network (not the internet) to the hosted secure EMIS data centre which is compliant with rigorous ISO standards. As the record is held simultaneously on the practice server and the EMIS data centre, if either system fails, then the other system will be available and the record will be protected offering greater security and functionality.
The practice controls access to individual patient records and only authorised users within our team can view your personal medical record. In most circumstances patient consent must be sought before information can routinely be shared with any other organisation and more information can be found on that in the following sections.
YOUR RIGHT TO PRIVACY
You have a right to know how we use your medical information and to keep your personal health information confidential between yourself and your doctor should you so choose. This applies to everyone over the age of 16 years and in certain cases, to those under 16. The law does impose a few exceptions to the rule. Very sensitive, personal information is strictly controlled by the law and anyone who receives information about you is under a legal duty to keep it confidential.
Please review the practice's FAIR PROCESSING / PRIVACY NOTICE by following the link below.
Fair Processing / Privacy Notice.
WHY WE KEEP INFORMATION AND WHY WE SHARE SOME INFORMATION
We keep information and details of the care you have received because it may be needed if we see you again. You may be receiving care from other people as well as the NHS and in order to work together for your benefit we may need to share some information about you. We only ever pass on information if people have a genuine need for it in your and everyone else's interests. Wherever possible, we remove details which identify you.
We also use information we hold to help us protect the health of the public generally; to assist with the planning of NHS services to ensure that they run efficiently and meet patient needs in the future; to prepare statistics on NHS performance and activity; to educate medical staff and to carry out health research for the benefit of everyone. We also use the information to review the care that we provide to make sure that it is of the highest standard and to investigate complaints or legal claims.
Your GP is required to share elements of your medical record, including some confidential personal and medical information, with the Health and Social Care Information Centre (HSCIC) and NHS England . Where the NHS deems it appropriate, data will be automatically extracted electronically from the practice computer system then linked with other data extracts from hospitals and social care records, in order to establish amalgamated health data records which do not currently exist. Your postcode or your NHS number will be used to link your records in a secure system. This data can then be used by the NHS for health planning or potentially, where appropriate, made available in an anonymised format to researchers outside of the NHS for health development. Sharing information should improve health and care outcomes for all patients; helping to improve the way that health care is delivered, improving services offered by the NHS and carrying out research into the treatments that can be offered for different diseases and illnesses.
If you are happy for your information to be used in this way you do not need to do anything, as the Practice is routinely required to permit the bulk extraction of this information upon receipt of approved requests. However, individual patients may instruct their Practice to stop the transfer of their practice based data where they are not happy to share this information. For more details, including how to opt out of your information being used for this purpose, please ask the receptionist for a copy of the Health & Social Care Information Centre patient leaflet ‘How information about you helps us to provide better care’.
WHO SEES YOUR INFORMATION
Our doctors, practice nurses, community nurses, midwives and health visitors all have access to the medical records of their patients. Other practice staff have limited access to your medical records. They need to notify the Health Authority of registration and claim details and carry out various filing tasks. By asking for certain information, you are giving your permission for a member of staff to look in your records.
Some information held about you may be shared with other people involved in your health care, eg doctors, nurses, therapists and technicians involved in the treatment or investigation of your medical problems.
We have to inform Health Authorities of patient registration changes, additions (including births) and deletions. We share limited information with them in order to help organise national health programmes (such as childhood immunisations, cervical smears and breast screening) and to report on certain procedures undertaken for which we are paid to perform.
We are required by lay to notify the Government of certain infectious diseases (eg meningitis, measles but not AIDS) for public health reasons. Law Courts can insist that GPs disclose medical records to them. Solicitors often ask for medical records and such requests must be accompanied by the patient's signed consent for us to disclose information.
Social Services & the Benefits Agency may, with the patient's consent, require medical reports from time to time to ensure the continuation of benefit payments or other support.
With a patient's consent, Life Insurance Companies & Potential Employers often ask for medical records from prospective clients / employees. GPs must disclose all relevant medical conditions, unless you ask us not to, in which case the insurance company will be advised that we have been instructed not to make a full disclosure.
FINDING OUT WHAT IS IN YOUR RECORDS
You are entitled by law to have access to your medical records. If you wish to see your records please ask for a copy of our Access to Records leaflet or contact the Practice Manager for advice. All requests to view records should be made in writing to the surgery.
WHAT WE WILL NOT DO
We will not disclose any medical information about you or give your test results over the phone unless we are absolutely sure that it is you. We will not disclose medical information to your family, friends or colleagues unless we have your consent to do so.
WHAT WE NEED YOU TO DO
Please do not ask our staff to disclose any details at all about patients over the phone, they are instructed to protect your privacy. Help us to meet your medical records accurate by informing us of any change in your name, address, or marital status and by ensuring that we have full details of your full medical history.
Everyone working for the NHS has a legal, ethical and contractual duty to protect your privacy and keep information about you confidential. The doctor - patient relationship sits at the heart of good practice and is based on mutual trust and confidence. If you have any further queries, comments or complaints about your medical records, then please contact the Practice Manager or speak to your GP.