The practice complies with Data Protection and Access to Medical Records legislation.
For this reason when telephoning for the surgery you will be asked to give your name, date of birth and address.
Everyone working for the NHS has a legal duty to keep information about you confidential (private). Your doctor or nurse should not disclose information about your health without your permission. This means you can tell others about your visit, but we won’t.
The law sets out how we can use your personal health information. The Data Protection Act gives you, the patient, rights about how your personal information is used, including a right to see the information we hold about you.
This applies to everyone over the age of 16 years and in certain cases to those under sixteen. The law does impose a few exceptions to this rule, but apart from those detailed below, you have a right to know who has access to their medical record.
Your Medical Records
To give you the care you need, we keep information about your visits to surgery staff who are involved in your treatment. These could be visits to a Doctor, Practice Nurse, Midwife, Health Visitor or Counsellor. We keep information about your health and lifestyle, and any illnesses, tests, prescriptions and other treatments that you have had because it may be needed the next time you are seen. This is called your medical records or medical notes. Your records are securely stored in a combination of paper and computer records.
Your GP is responsible for the accuracy and safe-keeping of your medical records. You can help us to keep it accurate by informing us of any change in your name, address, marital status and by ensuring that we have full details of your important medical history.
If you move to another area or change GP, we will send your medical records to the local patient demographics department (in Preston) to be passed on to your new practice. We will keep a copy of all computer entries into your records whilst you were registered with us. We also need to use your personal health information for administrative tasks, but we only use relevant information i.e. so that we can be paid for services we give you.
Sometimes, we might use information about you and other patients' to help improve our services, or to check that they are up to standard. Whenever we do this we will make sure that, as far as possible, we don't share any information that could identify you.
We may use some patient health information for other reasons: for example, to help us protect the health of the public generally and to ensure efficient running of the NHS through budgeting, staff training and financial accountability. Information may also be needed to help educate clinical staff and to carry out medical and other health research for the benefit of everyone.
Our Practice staff have access to medical records in order to make you appointments, give out test results and deal with any queries you may have e.g. over a prescription or letter about your healthcare. They also need to notify the CCG etc of registration and claim details and perform various administrative tasks on the medical records. All our Doctors, Nurses and other staff members have a legal, ethical and contractual duty to protect your privacy and confidentiality. Failure to do so is a disciplinary offence.
Other Professionals Who May See Your Records
There is a balance between your privacy and your safety. We will normally share some information about you with others involved in your health care, unless you ask us not to. This could include Doctors, Nurses, Therapists or other health professionals involved in the treatment or investigation of your medical problems. We only share relevant information.
For example, when your GP refers you to a specialist at the hospital we send relevant details about you in the referral letter and receive information back from them about you. We sometimes share information including your name, address and date of birth so that you can be invited for health screening. All NHS staff have a legal duty to keep information about you confidential and they follow a staff code of practice on protecting patient confidentiality.
You may be receiving care from other people as well as the NHS, for example if you need a service that we give jointly with your local authority. In this situation we will ask your permission before giving them your information. Sometimes we may need to share some information about you so that we can all work together for your benefit. We only ever use or pass on information about you if people have a genuine need for it and it is in your interests. Whenever we can, we will remove details which identify you. The sharing of some types of very sensitive personal information is strictly controlled by law. Anyone who receives information from us is also under a legal duty to keep it confidential.
This GP Practice is involved in teaching doctors. If you see a medical student during a consultation, they may be given supervised access to your medical record. We will not use or share your personal health information for research or teaching unless you have given your permission. Medical students are bound by the same rules of confidentiality as every other staff member.
Other Places Where Patient Information is Sent?
GPs must keep the health authority up to date with all registration changes: new patients and patients who leave the Practice or pass away. We also notify the CCG or public health departments of certain procedures that we perform and are paid for on an individual basis (e.g. minor surgery). This information does not include any information that could be used to identify the patient. Other limited information may be shared to help organise national programmes for public health such as childhood immunisations, cervical smear tests and breast screening.
Social Services, the Benefits Agency and other agencies may require medical reports on you from time to time. These will often be accompanied by your signed consent to disclose information. Failure to co-operate with these agencies can lead to patients' loss of benefit or other support. However, if we have not received your signed consent we will not normally disclose information about you.
The law courts can also insist that a GP discloses medical records to them. Doctors cannot refuse to cooperate with the court without risking serious punishment. We are frequently asked for medical reports from a Solicitor. These must always be accompanied by the patient's signed consent before we will disclose any information. We will not normally release details about other people that are contained in your records (e.g. wife, children, parents, etc) unless we also have their consent.
Life Assurance companies may request a medical report on prospective clients from the GP. These must always be accompanied by the patient's signed consent before we will disclose any information. GPs must disclose all relevant medical conditions unless you ask us not to do so. In such circumstances, we would need to inform the insurance company that you have instructed us not to make a full disclosure to them. You have the right, should you request it, to see reports to insurance companies or employers before they are sent.
Sometimes the law requires us to pass on information to other organisations. For example, we have to report all births, deaths and certain crimes or infectious diseases (e.g. Meningitis and measles but not HIV/AIDS) for public health reasons. The NHS Central Register for England & Wales contains basic personal details of all patients registered with a general practitioner. The Register does not contain clinical information.
How to View Your Medical Records
We are required by law to allow you access to your medical records. If you wish to see your records or would like copies of them, please request this in writing to our Practice Manager. We are allowed by law to charge a fee to cover our administration and costs.
What We Will Not Do
To protect your confidentiality, we will not disclose any medical information over the telephone or fax unless we are sure that we are talking to you. This means that we will not disclose information to your family, friends and colleagues about any medical matters at all, unless we know that we have your consent to do so.
Finally, if you have any further queries, comments or complaints about confidentiality and your medical records, then please write to the Practice Manager or talk to your GP.