Your Health Record
Confidentiality And Access To Patient Information
Any information that the doctor holds about you is very strictly confidential. Your doctor will not divulge ANY information about you to ANYONE, including your employer, insurance company or relative, without your written permission.
If you are referred to another doctor or health professional at the hospital or within the practice then necessary information will go with the referral and it is assumed that you agree with this if you have agreed to the referral.
If you don’t, you must say so to your doctor. ALL health professionals and staff within the practice are bound by the rule of confidentiality.
If you move to another practice your written and electronic records are transferred automatically to your new practice after you have registered with it.
There may be certain unusual circumstances where the doctor can be obliged to break the confidentiality rule, for instance if the patient is mentally incapacitated, or if it is in the interest of public safety, or if he or she is required by a court of law to do so.
National Data and Research
This practice is one of over 600 practices in England contributing pseudonymised data for national research and surveillance. These data enable continuous monitoring of infections and diseases in the community and is used in ethically approved research. The RCGP RSC is the main source of information for Public Health England (PHE) and helps with prediction and management of flu out-breaks and pandemics. Providing pseudonymised data does not affect patients, their care or privacy, however if you no longer wish to allow your information to be used, please speak to your GP.
Your Personal Data
We take your personal data extremely seriously and take every precaution to ensure it is safe and secure. When you attend an appointment or contact the surgery you may be asked to confirm your contact details with a receptionist or clinician. This is to ensure that we have your correct details such as address, mobile number and email address associated with your clinical record; to enable us to communicate with you about your health in a quick, efficient and secure manner.
Our policy is that normally every young person 14 and above has their own mobile number on their records for confidentiality reasons. If this applies to you or a family member, please contact the surgery to make the necessary changes
Below are 2 leaflets that explains how NHS England and our surgery are sharing your medical information to enable to offer the best possible care:
Freedom of Information
Information about the General Practioners and the practice required for disclosure under this act can be made available to the public. All requests for such information should be made to the Site Manager.
Access to Records
In accordance with the Data Protection Act 1998 and Access to Health Records Act, you are entitled to know what information is held about you and if you wish to know you should simply ask your doctor or make an arrangement with the site manager. No information will be released without the patient consent unless we are legally obliged to do so.
About health records
Health records play an important role in modern healthcare. They have two main functions, which are described as either primary or secondary.
Primary function of health records
The primary function of healthcare records is to record important clinical information, which may need to be accessed by the healthcare professionals involved in your care.
Information contained in health records includes:
- the treatments you have received,
- whether you have any allergies,
- whether you’re currently taking medication,
- whether you have previously had any adverse reactions to certain medications,
- whether you have any chronic (long-lasting) health conditions, such as diabetes or asthma,
- the results of any health tests you have had, such as blood pressure tests,
- any lifestyle information that may be clinically relevant, such as whether you smoke, and
- personal information, such as your age and address.
Secondary function of health records
Health records can be used to improve public health and the services provided by the NHS, such as treatments for cancer or diabetes. Health records can also be used:
- to determine how well a particular hospital or specialist unit is performing,
- to track the spread of, or risk factors for, a particular disease (epidemiology), and
- in clinical research, to determine whether certain treatments are more effective than others.
When health records are used in this way, your personal details are not given to the people who are carrying out the research. Only the relevant clinical data is given, for example the number of people who were admitted to hospital every year due to a heart attack.
Types of health record
Health records take many forms and can be on paper or electronic. Different types of health record include:
- consultation notes, which your GP takes during an appointment,
- hospital admission records, including the reason you were admitted to hospital,
- the treatment you will receive and any other relevant clinical and personal information,
- hospital discharge records, which will include the results of treatment and whether any follow-up appointments or care are required,
- test results,
- photographs, and
- image slides, such as those produced by a magnetic resonance imaging (MRI) or computerised tomography (CT) scanner.
There are strict laws and regulations to ensure that your health records are kept confidential and can only be accessed by health professionals directly involved in your care.
There are a number of different laws that relate to health records. The two most important laws are:
- Data Protection Act (1998), and
- Human Rights Act (1998).
Under the terms of the Data Protection Act (1998), organisations such as the NHS must ensure that any personal information it gathers in the course of its work is:
- only used for the stated purpose of gathering the information (which in this case would be to ensure that you receive a good standard of healthcare), and
- kept secure.
It is a criminal offence to breach the Data Protection Act (1998) and doing so can result in imprisonment.
The Human Rights Act (1998) also states that everyone has the right to have their private life respected. This includes the right to keep your health records confidential.
The NHS is currently making some important changes to how it will store and use health records over the next few years. See the Service description section for more information.
For more information please follow the links below.