Your Health Record
A guide to how information about you is used in the NHS.
Why might we have your medical record
Medical records are normally held by your GP practice or other organisations that provide care for you, such as hospitals or providers of community-based services like district nursing or mental health.
What information would you normally have about me on your computers and in writing?
- Your name, address, date of birth, next of kin.
- Why you need care and treatment.
- When and where you have been seen.
- What happened when you were seen.
- Ethnic group, religious affiliation.
- Information based on the professional opinion of the staff caring for you.
Why might you have information about me?
- To review the care you receive care to ensure it is of the highest standard.
- To check staff and services are working well.
- To plan new services.
- You have appealed against an individual funding decision.
- If you have made a complaint to us. We may pass your information on to our support unit for them to investigate on our behalf. In that case we will get in touch with you.
- If there are compelling reasons for us to have personal medical information about you, such as to assure the quality of a service or to make sure you are receiving the care you need.
- If you are at risk and need support from our children’s or adult safeguarding teams.
Do I have to give you my information?
- We need your information if it concerns decisions about you and your care and treatment.
- Information about you helps us to work with care professionals such as doctors and nurses to plan new services and treatments.
- You can say no to us using your information for this.
Do you share my information with other people?
Sometimes we talk to people such as other doctors or social services to make sure you receive all the care you need. We will always try to talk to you before we talk to them.
Information may be shared in the event of a medical emergency concerning you, or where there is civil emergency (such as bad weather) and we need to make sure local services can cope.
Who can see my information?
We only let people who really need to see your information have it. The people who care for you need to know about you. But where we can we don’t use your name or address.
Can I see my health record?
Yes, you can.
You can access your records online, by using our online services, Patient Access.
Will I see all my information?
Usually you will.
Very rarely there may be medical or legal reasons why we cannot share everything with you.
How can I see the records we hold about you?
- Through Patient Access: www.app.patientaccess.com
- Our Medical Reports form
- Phone:01737 244325
If you do need a record from us, please write to the medical reports administrator:
The Wall House Surgery
You may be charged an administration fee.
You should be aware that in exceptional circumstances some information may be withheld to protect you from undue harm, or where a third party is involved.
How we use your information to help you
We may keep records about your health and the care you receive. This information is stored on both paper and computer systems.
This is important because:
- The staff caring for you have accurate, up to date information to help them decide the best possible care and treatment for you.
- We need to make sure that treatments and services meet the needs of local communities.
- That full information is available should you need another form of care, for example if you are referred to a specialist service.
- That there is a good basis for looking back and checking on the type and quality of care you received.
- We sometimes need to look back and check on the type and quality of care you and people like you received.
- That your concerns can be properly looked into if you have made an individual request for service through us or have a complaint.
Your information also helps us to plan health services for the future both locally and nationally. It also allows us to monitor the way public money is spent.
Keeping your information confidential
Everyone working for the NHS has a legal duty to keep the highest level of confidentiality.
Generally your records will only be seen by those involved in providing or administering your care. A few administrative processes require information that may identify you, however most processes will use anonymous information.
Occasionally, we might share your information with:
- Your general practice and pharmacies
- Local authority departments, including social services, education and housing
- NHS walk-in centres
- NHS Direct & Care Direct
- Out of hours doctors services
- Community services such as nurses, midwives and therapists
- Voluntary organisations
- Private hospitals, care homes, hospices
We will talk to you before information is shared to ensure we act with your consent.
If we are unable to seek your consent, then we will only share information where it is clearly in your best interests to do so, or if there is a compelling legal reason to do so.
With your consent, information can be shared with relatives, partners or friends who act as a carer for you.
When information is shared, it is passed securely and kept confidential by the people who receive it. It will only be used for the purpose for which it has been shared.
Education and Research
We might share your information to help with:
- Training and educating our staff
- Research approved by the Local Research Ethics Committee.
We will normally remove anything that identifies you.
On rare occasions it might be helpful to personally identifiable information (i.e. about you). If so we will ask for your consent and make sure that the information is only used for what you consented to.
Sharing your information without consent
We will normally ask for your consent but there are times when we may need to share your information without your consent, for example:
- Where there is a risk of harm or abuse to you or other people.
- Where a serious crime, such as an assault, is being investigated or where it could be prevented.
- To control infectious diseases such as meningitis, tuberculosis (tb) or measles.
- Notification of a birth.
- Where the courts have made a formal order in relation to a court case.
- Where there is a legal requirement: some authorities can make special applications for information using specific legal processes.
We will try to inform you if we have to share your information without your consent.
Information for managing and planning
The NHS register for England and Wales contains basic personal details of all patients registered with a general practitioner (GP) in order to manage the administration of practice lists.
So that the NHS can manage and plan services, some information about you is sent to the organisation responsible for your care, and to the Department of Health.
As far as possible this information will not identify you. The information is used for a variety of purposes such as to pay organisations for the care they provide, investigate complaints or untoward incidents and to look after the health of the general public.
Further use of centrally held information is strictly controlled by the Department of Health and advisory bodies such as the Patient Information Advisory Group.
Information held centrally is not used to make any decisions about the treatment or care that you receive from your hospital or GP.