Practice Policies

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.

Freedom of Information

Information about the General Practitioners 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.

Complaints

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.

Violence Policy

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.

Chaperone Policy

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.   Please ask at Reception if you require a chaperone.

How do I give consent for a member of my family or a carer to contact the surgery on my behalf?

At Dr Mitchells’ 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
• X-rays
• 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)