Confidentiality & Medical Records
The practice complies with data protection and access to medical records legislation. Identifiable information about you will be shared with others in the following circumstances:
- To provide further medical treatment for you e.g. from district nurses and hospital services.
- To help you get other services e.g. from the social work department. This requires your consent.
- When we have a duty to others e.g. in child protection cases anonymised patient information will also be used at local and national level to help the Health Board and Government plan services e.g. for diabetic care.
If you do not wish anonymous information about you to be used in such a way, please let us know.
Reception and administration staff require access to your medical records in order to do their jobs. These members of staff are bound by the same rules of confidentiality as the medical staff.
Each of our patients has a 'named GP' - Dr Robert G Mitchell.
The named or 'usual GP' mainly performs an administration role in overseeing care on behalf of the patient.
It is always helpful, for your continuity of care, if you can follow through a medical problem that you may have with the same GP but we appreciate that this may not always be possible due to GP availability.
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 practice manager.
Access to Records
In accordance with the Data Protection Act 1998 and Access to Health Records Act, patients may request to see their medical records. Such requests should be made through the practice manager. No information will be released without the patient consent unless we are legally obliged to do so.
We make every effort to give the best service possible to everyone who attends our practice.
However, we are aware that things can go wrong resulting in a patient feeling that they have a genuine cause for complaint. If this is so, we would wish for the matter to be settled as quickly, and as amicably, as possible.
To pursue a complaint please contact the Practice Manager who will deal with your concerns appropriately. Further written information is available regarding the complaints procedure from reception.
The NHS operate a zero tolerance policy with regard to violence and abuse and the practice has the right to remove violent patients from the list with immediate effect in order to safeguard practice staff, patients and other persons. Violence in this context includes actual or threatened physical violence or verbal abuse which leads to fear for a person’s safety. In this situation we will notify the patient in writing of their removal from the list and record in the patient’s medical records the fact of the removal and the circumstances leading to it.
We understand patients can sometimes find some consultations, examinations and procedures distressing and uncomfortable. This policy is designed to protect both patients and staff from abuse or allegations of abuse and to assist patients to make an informed choice about their examinations and consultations. A variety of people can act as a chaperone in the practice. Chaperones may be termed 'formal' and 'informal'. Formal chaperones are clinical staff familiar with procedural aspects of personal examination e.g. HCA or Nurse. Informal chaperones can be present as many patients feel reassured by the presence of a familiar person and this request in almost all cases should be accepted.
How do I give consent for a member of my family or a carer to contact the surgery on my behalf?
At Dr Mitchell's surgery we will never discuss your medical information with someone unless you have given consent for us to do so. As a patient you are able to add third party consent to you record by returning the third party consent form. Please note you may only wish for that person to discuss only certain aspects of your health and record with us (for example just test results) you do not have to give them full access if you do not wish to do so.
Your Health and Care Records
What is meant by health record?
Wherever you visit an NHS service a record is created for you. This means medical information about you can be held in various places, including your GP practice, any hospital where you’ve had treatment, your dentist practice, and so on.
Since April 2015 all GPs should offer their patients online access to summary information of their GP records. To find out more about how to access medical records online or in paper see the section How to access your health records. - (NHS Choices Website)
A health record (sometime referred to as medical record) should contain all the clinical information about the care you received. This is important so every health professional involved at different stages of your care has access to your medical history such as allergies, operations or tests. Based on this information, the health professional can make judgements about your care going forward.
Your health records should include everything to do with your care including x-rays or discharge notes. The data in your records can include:
- treatments received or ongoing
- information about allergies
- your medicines
- any reactions to medications in the past
- any known long-term conditions, such as diabetes or asthma
- medical test results such as blood tests, allergy tests and other screenings
- any lifestyle information that may be clinically relevant, such smoking, alcohol or weight
- personal data, such as your age, name and address
- consultation notes, which your doctor takes during an appointment
- hospital admission records, including the reason you were admitted to hospital
- hospital discharge records, which will include the results of treatment and whether any follow-upa ppointments or care are required
- photographs and image slides, such as those produced by a magnetic resonance imaging (MRI) or computerised tomography (CT) scanner
Find out how long medical records are kept for. - (NHS Choices Website)
Keeping your online health and social care records safe and secure
Guidance is available to help you understand what an electronic health and care record is, how you can access it, who you may want to share it with and how to perform these actions securely. This guidance was created by the Department of Health, working in collaboration with BCS, the Chartered Institute of IT, in 2013.
Download the patient guidance booklets:
Patient guidance booklet (PDF, 395kb)
Patient guidance summary A4 (PDF, 130kb)
Types of health record
What is a Summary Care Record?
All the settings where you receive healthcare keep their own medical records about you. These places can often only share information from your records by letter, fax or phone. At times this delays information sharing which can affect decision making and slow down treatment. To help improve the sharing of important information about you, the NHS in England is using an electronic record called the Summary Care Record.
Your Summary Care Record contains important information from the record held by your GP practice and includes details of any medicines you are taking, any allergies you suffer from and any bad reactions to medicines that you have previously experienced. Your Summary Care Record also includes your name, address, date of birth and your unique NHS Number to help identify you correctly.
You may want your GP to add other details about your care to your Summary Care Record. This will only happen if both you and your GP agree to do this. You should discuss your wishes with your GP practice.
Allowing authorised healthcare staff to have access to this information helps to improve decision making by doctors and other healthcare staff and has prevented mistakes being made when patients are being cared for in an emergency or when their GP practice is closed.
Access to your Summary Care Record is strictly controlled. The only people who can see the information is the healthcare team currently in charge of your care. They can only access your records via a special smartcard and access number (like a chip-and-pin card). Healthcare staff will ask your permission every time they need to look at your Summary Care Record. If they cannot ask you, e.g. because you're unconscious, healthcare staff may look at your record without asking you. If they have to do this the decision will be recorded and checked to ensure that the access was appropriate.
You can choose to opt out of having a Summary Care Record at any time. In that case, you need to let your GP practice know by filling in an opt-out form (PDF, 245.9kb). If you are unsure if you have already opted out you should talk to the staff at your GP practice. If you change your mind again simply ask your GP to create a new Summary Care Record for you.
Find more information about Summary Care Records
Read the Summary Care Record patient leaflet (PDF, 888.2kb)
How we use your personal information
This fair processing notice explains why the GP practice collects information about you and how that information may be used.
The health care professionals who provide you with care maintain records about your health and any treatment or care you have received previously (e.g. NHS Trust, GP Surgery, Walk-in clinic, etc.). These records help to provide you with the best possible healthcare.
NHS health records may be electronic, on paper or a mixture of both, and we use a combination of working practices and technology to ensure that your information is kept confidential and secure. Records which this GP Practice holds about you may include the following information:
Details about you, such as your address, carers, legal representative, emergency contact
Any contact the surgery has had with you, such as appointments, clinic visits, emergency appointments etc.
Notes and reports about your health
Details about your treatment and care
Results of investigations such as laboratory tests, X-rays etc
Relevant information from other healthcare professionals and those who care for you
To ensure you receive the best possible care, your records are used to facilitate the care you receive. Information held about you may be used to help protect the health of the public and to help us manage the NHS. Information may be used within the GP practice for clinical audit to monitor the quality of the service provided.
Some of this information will be held centrally and used for statistical purposes. Where we do this, we take strict measures to ensure that individual patients cannot be identified. Sometimes your information may be requested to be used for research purposes – the surgery will always gain your consent before releasing the information for this purpose.
Risk stratification data tools are increasingly being used in the NHS to help determine a person’s risk of suffering a particular condition, preventing an unplanned or (re)admission and identifying a need for preventive intervention. Information about you is collected from a number of sources including NHS Trusts and from this GP Practice. A risk score is then arrived at through an analysis of your de-identified information using software managed by emBed Consortium, and is only provided back to your GP as data controller in an identifiable form. Risk stratification enables your GP to focus on preventing ill health and not just the treatment of sickness. If necessary your GP may be able to offer you additional services.
Please note that you have the right to opt out of your data being used in this way. Privacy Notice (February 2017)
The Practice may conduct Medicines Management Reviews of medications prescribed to its patients. This service performs a review of prescribed medications to ensure patients receive the most appropriate, up to date and cost effective treatments. This service is provided to practices within the East Riding of Yorkshire Clinical Commissioning Group Commissioning Support Unit.
How do we maintain the confidentiality of your records?
We are committed to protecting your privacy and will only use information collected lawfully in accordance with:
Data Protection Act 1998 and General Data Protection Regulation 2016
Human Rights Act 1998
Common Law Duty of Confidentiality
Health and Social Care Act 2012
NHS Codes of Confidentiality, Information Security and Records Management
Information: To Share or Not to Share Review
Every member of staff who works for an NHS organisation has a legal obligation to keep information about you confidential.
We will only ever use or pass on information about you if others involved in your care have a genuine need for it. We will not disclose your information to any third party without your permission unless there are exceptional circumstances (i.e. life or death situations), where the law requires information to be passed on and / or in accordance with the new information sharing principle following Dame Fiona Caldicott’s information sharing review (Information to share or not to share) where “The duty to share information can be as important as the duty to protect patient confidentiality.” This means that health and social care professionals should have the confidence to share information in the best interests of their patients within the framework set out by the Caldicott principles. They should be supported by the policies of their employers, regulators and professional bodies.
Who are our partner organisations?
We may also have to share your information, subject to strict agreements on how it will be used, with the following organisations:
NHS Trusts / Foundation Trusts
NHS Commissioning Support Units
Independent Contractors such as dentists, opticians, pharmacists
Private Sector Providers
Voluntary Sector Providers
Clinical Commissioning Groups
Social Care Services
Health and Social Care Information Centre (HSCIC)
Fire and Rescue Services
Police and Judicial Services
Other ‘data processors’ which you will be informed of
Privacy Notice (February 2017)
You will be informed who your data will be shared with and in some cases asked for explicit consent for this happen when this is required.
We may also use external companies to process personal information, such as for archiving purposes. These companies are bound by contractual agreements to ensure information is kept confidential and secure.
Access to personal information
You have a right under the Data Protection Act 1998 to request access to view or to obtain copies of what information the surgery holds about you and to have it amended should it be inaccurate. In order to request this, you need to do the following:
Your request must be made in writing to the GP – for information from the hospital you should write direct to them
We are required to respond to you within one month.
You need to give adequate information (for example full name, address, date of birth, NHS number and details of your request) so that your identity can be verified and your records located
Objections / Complaints
Should you have any concerns about how your information is managed at the practice, please contact the Practice Manager. If you are still unhappy following a review by the GP practice, you can then complain to the Information Commissioners Office (ICO) via their website (www.ico.gov.uk).
If you are happy for your data to be extracted and used for the purposes described in this privacy notice then you do not need to do anything. If you have any concerns about how your data is shared then please contact the practice.
Change of Details
It is important that you tell the person treating you if any of your details such as your name or address have changed or if any of your details such as date of birth is incorrect in order for this to be amended. You have a responsibility to inform us of any changes so our records are accurate and up to date for you.
The Data Protection Act 1998 requires organisations to register a notification with the Information Commissioner to describe the purposes for which they process personal and sensitive information.
This information is publicly available on the Information Commissioners Office website www.ico.org.uk
The practice is registered with the Information Commissioners Office (ICO).
Who is the Data Controller?
The Data Controller, responsible for keeping your information secure and confidential is:
Dr R G Mitchell
Should you have any concerns about how your information is managed by the Practice please contact the Practice Manager at the following address:
Dr R G Mitchell's Surgery, 15 School Lane, North Ferriby HU14 3DB
If you are still unhappy following a review by the Practice you can then complain to the Information Commissioners Office (ICO). www.ico.org.uk, email@example.com, telephone: 0303 123 1113 (local rate) or 01625 545 745.