Your Medical Records and Data Protection
We use computers extensively in the practice to record information about patients and their medical conditions. Some of this information we obtain from you personally and some is obtained from the NHS and other organisations. Such information is essential so that you can receive proper care and treatment. As the need arises, we also share some of the information we hold with health authorities, hospitals and other healthcare organisations.
All our staff are trained to understand the need for confidentiality, and we take care not to disclose information to anyone who is not authorised to see it, even to members of your own family. Normally, we seek your permission to disclose information to a third party, unless we believe it is in your interests or the interests of public health or safety that the information is disclosed, or unless we are required to do so by law, and then only the minimum necessary. Whenever possible, information is anonymised or coded to avoid unnecessary disclosure. Patients have the right to object to or complain about any disclosures of their medical records.
Summary Care Record – your emergency care summary The NHS in England has introduced the Summary Care Record, which will be used in emergency care. The record contains information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines you have had to ensure those caring for you have enough information to treat you safely. Your Summary Care Record will be available to authorised healthcare staff providing your care anywhere in England, but they will ask your permission before they look at it. This means that if you have an accident or become ill, healthcare staff treating you will have immediate access to important information about your health. When you register as a patient with us you will be asked to complete a form indicating whether you want to have a summary care record and to share your electronic record with other care services.
For more information please contact the NHS Summary Care Record Information Line on 0300 123 3020, or visit www.nhscarerecords.nhs.uk. Additional copies of the opt out form can be collected from the practice or printed from this website. You can choose not to have a Summary Care Record and you can change your mind at any time. Children under 16 will automatically have a Summary Care Record created for them unless their parent or guardian completes an opt out form on their behalf requesting us to consider opting them out. If you are the parent or guardian of a child under 16 and feel that they are old enough to understand, then you should make this information available to them.
Today, electronic records are kept in all the places where you receive healthcare. These places can usually only share information from your records by letter, email, fax or phone. At times, this can slow down your treatment and mean information is hard to access. However, this practice uses a unique computer system called SystmOne that allows the sharing of full electronic records across different healthcare care services. We are telling you about this so that you can think about your choices:
You can choose to share your electronic record with other care services, or
You can choose not to share your electronic record with other care services.
To find out more, please read the information leaflet.
Patients in Leicester, Leicestershire and Rutland now have the opportunity to have their medical record shared with health professionals other than with staff at their GP practice. Patients will now be asked if they wish to give permission for the health care professional treating them in a hospital or urgent care setting, or out of hours (evenings and at weekends) to see their medical record. Sharing a patient record will help improve the quality of your care and potentially save lives. Patients are still in control of choosing which organisations’ health professionals are permitted to see their medical records and will always be asked for permission to view their record by the health professional concerned. For further information please visit www.bettercareleicester.nhs.uk.
NHS England has launched an animated video to raise awareness of how patient data are set to be collected and used to help improve care for all. The video, ‘Better Information Means Better Care’, compliments a leaflet of the same name that has recently been delivered to households in our area. The Health and Social Care Information Centre (HSCIC) is the national NHS organisation with a legal responsibility to collect data as people make use of NHS and social care services. Information about you is used in a number of ways by the NHS and social care services to support your personal care and to improve health and social care services for everyone. Further information is available from the NHS Choices website.
Patients’ access online to information from the medical record
For some time patients have been able to book appointments, request repeat prescriptions and view their summary care record on-line. Patients can now request access to detailed coded information in their medical records, the Detailed Coded Record, superseding the summary care record which is no longer available on-line.
These are the categories of information that are included in the Detailed Coded Record (DCR).
• Allergies/adverse reactions
• Medication (dose, quantity and last date issued)
• Results (numerical values and normal range)
• Values (BP, PEFR)
• Procedure codes (Medical or surgical) and codes in consultations (signs and symptoms)
• Codes showing referral made or letters received (not the letter itself)
• Other codes (ethnicity, QOF).
If you would like to have access to your DCR, please apply in person to the practice, and bring with you the completed application form, photo ID and confirmation of address as we have to verify your identity in view of the sensitive nature of the information. Patients who are already registered for online services will also need to renew their registration by completing the application form and refresh their photo ID to extend this to include DCR. You can download the information and application form from here.
Patients can have access to their medical records under the Data Protection Act 1998. There is a fee of up to £50 for copies of your paper-based records or up to £10 for copies of the computer records. If you need to see your medical records you should contact our receptionist who will make an appropriate appointment. Full policy on rights of access to medical records.
National Diabetes Audit
This GP practice takes part in an important national project about people at risk of diabetes and diabetes care and treatment in the NHS. The project is called the National Diabetes Audit (NDA). If you have diabetes, non-diabetic hyperglycaemia, impaired glucose tolerance or pre-diabetes, we will share information about your diabetes care and treatment with the NDA. The type of information, and how it is shared, is controlled by law and enforced by strict rules of confidentiality and security. For further information about how your data is used, please see the NDA patient information leaflet. If you do not want your information to be used, please inform the receptionist, your GP or nurse. This will not affect your care. Taking part in the NDA shows that this practice is committed to reducing diabetes and improving care for people with diabetes.
Freedom of Information Act 2000
You can download a leaflet explaining the Practice’s Publication Scheme as required by the Freedom of Information Act 2000. Alternatively, please ask one of our receptionists for assistance with your query.