Why we hold it? How we hold it? Who uses it? And your rights over it?
At GP Direct we hold information related to your medical care as this is necessary for us to offer you a high standard of care. The information we hold is treated in the strictest confidence and we are careful to ensure it is stored safely in accordance with The Data Protection Act.
Why we hold it?
We need to hold information about all of our patients so that we can offer a high level of medical care. We need to know what underlying medical conditions you may have, recent investigations or the types of medication you are prescribed and this along with other medical information needs to be stored on our premises so that we can access it.
How we hold it?
Your information is held in two ways, firstly you have a paper record and secondly you have an electronic record.
In relation to the paper record this will contain past medical issues as we no longer record medical information in the paper record and have not done so since the late 90s, this is still an important part of your medical care and as such we summarise the key elements straight onto your electronic record, for example we summarise diseases, major investigations and other issues that are deemed to be of medical significance to your continuing care.
If you were to see a doctor or nurse today the resulting consultation would be added to your electronic record. The introduction of electronic clinical software has made the data we hold of a better standard as it is clear (i.e. word processed), read coded (it is coded so we can for example identify all the Asthma patients who need their annual review by a simple search) and is easier to access and manage. Any staff member accessing your record will have signed a confidentiality agreement not to disclose any of this information outside their normal course of employment.
Who uses it?
Practice staff are the main people who use your record, such as the doctors, nurses and other clinical staff, additionally the admin and receptionist team will need to have access to make appointments, send referrals and follow up queries on behalf of the clinicians.
You record may also be accessed and edited by allied health care professionals, such as the Health visitor, Midwife, Physiotherapist, Counsellor etc. These professionals will be NHS based and will come from a recognised NHS establishment such as Northwick Park Hospital.
As time goes by it is envisaged that it the health record can be accessed and edited if you have to be seen in local NHS walk-in centres or in the Urgent Care Centre at Northwick Park.
Your rights over it?
Some people do not like to have their information shared with anyone outside the practice. In these situations we ask that you inform us clearly in writing so that we can make sure this is noted on your record.
The Access to Medical Records Act 1990 gave you, the patient, the statutory right to see your health record but only applied to material held on paper. The Data Protection Act 1998 extended the right of access to records held on computer and came into force on 1st March 2000.
While you can apply for access to your own record it is an infrequent occurrence. More often it is a third party (e.g. a legal representative) that will apply on your behalf with your consent for things like Personal injury claims, life insurance applications etc.
Parents can have access to their child’s records if it is in the child’s interest. People appointed by the courts to manage the affairs of mentally incapacitated adults may also gain access to the patient’s notes.
Information will not be disclosed if it is likely to cause serious physical or mental harm to the patient or to another person. Access will be refused if the information relates to a third party who has not given consent for disclosure. We have to check the health record carefully before releasing it.
Third party access
The key issue is informed consent, in other words that you the patient understands the implications of the information being released. Once we are satisfied that the consent is valid and that you the patient will not come to any harm if the information is divulged we can proceed with the request.
If you wish to see your medical record but do not want a copy the charge is a maximum of £10. However, if material has been added to the record in the previous 40 days, you can see your whole record free of charge. If we receive a request a print-out will be made and shown to you but you cannot take it off the premises.
GP Direct is legally obliged to provide you with a copy of your notes and can charge a reasonable fee – capped at £10 for records held wholly on computer and £50 for any that are part electronic and part on paper.
Requests for access to the records of deceased patients are usually in relation to wills or complaints about the patient’s treatment. These fall into two categories: those made by an agent acting in the patient’s interests (usually a legal representative) and those made by other parties (e.g. the police or insurers).
Exemptions are essentially the same as for a living patient. If we are aware that the patient made a stipulation about access to their records before their death, we are obliged to comply.