How We Use Your Medical Record

Important information for patients. Here are our new Privacy Rules

How we use your information, Fair Processing and Privacy Notice

Childrens Privacy Information leaflet

Confidentiality and Your medical Record

What you tell us – When you visit the surgery we want you to feel able to discuss anything with your Doctor that might relate to your health. This may include sexual matters, your relationship, drugs, drinking, your mental health, your job etc.

The General Medical Council, whose rules on confidentiality apply to all Doctors in the UK, enforces our duty of confidentiality to all patients. The Practice is also registered under the Data Protection Act 1998.

We take great care to ensure that no information you give to us is passed on either inadvertently or though the deception of others.

When you leave our practice and register with another one elsewhere, your medical records may be transferred electronically to that practice, by a system called GP2GP. This system is highly secure and only your new practice will be able to read the file sent to them. Your paper based records will continue to be sent to the patient and practitioners service at the CCG for forwarding to your new practice.

Members of your family – If you become ill it is understandable that your partner, family or carer will be concerned about you and may want to talk to the Doctor, however the Doctor cannot talk to them without your written consent. It may be easier to bring them with you when you come to see the Doctor if you are happy with them being present during your consultation.

You are worried about a relative – Sometimes you may be worried about a relative but he or she refuses to see their Doctor and you feel its important the Doctor knows of their illness. In such circumstances you can write to the Doctor or make an appointment. The Doctor will not be able to discuss your relatives medical record with you but may be able to act on the information you have provided. It is always advisable to tell the patient you are going to talk to the Doctor about them.

Releasing information without your agreement – There are a few situations when your Doctor is allowed to release information without consent. These situations are very rare and are defined by law. Such information can only be passed on to relevant authorities if you are:

1. Profoundly Mentally ill

2. Have serious infection which can be passed on easily to the general public (Not sexually transmitted diseases).

3. Are at risk of very serious harm or death.

The Doctor would make a judgment based on the individual circumstances before going against your wishes.

Reports – Sometimes you may need a report prepared by your Doctor for someone else who is not involved in your acre. This mat be your employer, an insurance company or your solicitor. We will never release any information to any other party without your written consent. You have the right to see these reports before they are sent off. If you have any worries we recommend you ask to check them at the time.

Access to medical records – You have the right to see your own medical record, which may be paper based or held electronically. You should apply In writing to the practice manager who will arrange an appointment. The only time information contained in your record may be withheld is where there is a risk it could cause physical or mental harm to either yourself or a third party or it relates to a third party who has not given permission for disclosure.

Referrals –  Sometimes you may need to be referred to a consultant or other medical professional. This will require sending details from your medical history to that person. Your referral may also go through a Choose and Book (CAB) system to allow you to choose which hospital you would like to attend.

Practice Staff – Doctors do not discuss their patients with reception staff, but staff may type letters, file incoming hospital post and results and carry out a host of other administrative tasks on behalf of your Doctor. They are not allowed to access your notes for any other purpose. All staff are highly trustworthy and professional in their attitude to the responsibility that patient confidentiality places in the.

When staff ask you for details of your illness when you ring to make an appointment they are not being nosy, they request the information to ensure you are offered an appointment for the appropriate length of time, with the most appropriate clinician and, if the requests involves a phone call from a GP, to allow them to prioritise the calls.

Information to the Health Authority and other health organisations – Some information is sent electronically to the Health Authority, mainly statistical information for the calculation of payments to the Doctors for their work. Some personal details such as change of address etc are sent but no clinical information that is identifiable to a particular patient is transmitted.

No one outside the building can access the computer or the information that is sent to the Health Authority. Health Authority staff are also bound by the same rules on data protection and confidentiality.

The Practice is also requested by the NHS to provide data for clinical audit of certain diseases and conditions. Prescribing information is also requested to help compile statistics on how diseases are treated and the cost involved in treating some illnesses. All such information is anonymous, with no patient identifiable information being passed on.

Computer Security – All persons who can access your record on the computer are given a unique password. Different grades of staff have different levels of access. Staff should only have access to those parts of the computer record that they need to do their job. An audit trail of who has used the computer is kept within the computer system with every login recorded and identified by the user’s password. All computers have anti-virus software loaded, which is regularly updated to protect your medical records.