Policies

Your medical record is your lifelong medical history. It holds details of your consultations, illnesses, tests, prescriptions and other treatments that have been written by everyone involved in your treatment and care e.g. district nurses, social services etc. By consulting this information we are able to provide you with the best, most appropriate health care.

Some of this information is held electronically on computer and some on paper. It is kept as a history of your treatment to ensure you receive the best possible care now and in the future. Your GP is responsible for the accuracy and safekeeping of your medical records.

Risk Profiling

Our members of staff are trained in information security and confidentiality. There are strict codes of conduct in place to ensure that all your information, be it on paper or computer, is safe. It is written into all our staff contracts that it is a serious disciplinary offence to breach confidentiality and may lead to a staff member’s dismissal.

If you disclose sensitive information that you strongly feel should not be shared with the practice team please discuss this in your consultation to enable the doctor or nurse to take appropriate action in their record keeping. This is a teaching and training practice and undergraduate students and GP registrars may be involved in your consultation. Your permission to participate in consultations with these doctors will always be sought.

This practice needs information about you so that you can receive the best possible care and treatment. It may be needed if we see you again, or shared with other organisations involved in your care. We may need to use some of this information, for example:

  • To help protect the health of the public generally – we are required by law to notify the government of certain diseases, e.g. meningitis or measles, but not AIDS.
  • Planning for the future – this includes sending information to Health Authorities and the Department of Health e.g. breast screening etc.
  • Training staff.
  • Auditing accounts.
  • To carry out other health research by use of statistics (your personal details will be non-identifiable) e.g. waiting list information.
  • Investigating complaints or legal claims – your information will need to be accompanied by your written consent before being passed on to solicitors etc.
  • Sometimes the law requires us to pass on information e.g. to notify a birth or death.

When you sign to give permission for your representative (solicitor etc.) to access your records, please be aware that this gives consent for that person to access the WHOLE of your medical record, when you may only intend that they should have access to the part of it that is relevant to your needs. Your records may contain information that you would rather withhold from such representation. You may wish to stipulate to which part/s of the record they may have access. 

You may be receiving care from other people as well as your GP (e.g. NHS Hospital Trust, Social Services, private hospitals etc). So that we can all work together for your benefit we may need to share some information about you.

We only ever pass on information about you if it is in your interest with regard to your health. Whenever we can we shall remove details which identify you. The law strictly controls the sharing of some types of very sensitive personal information. Your personal details will not be used for research purposes unless you have been informed beforehand and given your consent for us to do so.

In order to assure the quality of the care and training we provide our clinical records are sometimes inspected by outside visitors. The visitors must make undertakings to keep your records confidential before we will allow them to see them. You can refuse to participate in these inspections by informing the reception staff appropriately.

We have an obligation by law to allow you access to your records. We are allowed to charge a fee to cover our administration and photocopying costs. Please see the charging structure. All requests to access medical records must be in writing for security purposes. We have a duty to keep your medical records accurate and up to date. If any errors of fact have appeared in your record, please draw our attention to them so that they can be corrected.

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