Your Medical Record
What information do you have about me on your computers and in writing?
- Your name, address, date of birth
- Why you need care and treatment
- When and where you have been seen
- What happened when you were seen
Why do you have information about me?
- To give you good care and treatment
- To check you and other people get good care and treatment
- To check our staff are working well
- To plan new services
Do I have to give you my information?
- We must have information to give you care and treatment
- Information helps us to teach doctors and nurses and to make new 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 an emergency situation or for emergency response or recovery purposes.
Who can see my information?
The people who care for you need to know about you. Where we can we don’t use your name or address.
We only let people who really need to see your information have it.
Can I see my health record?
Yes, you can. Just ask us and we will tell you what to do.
Will I see all my information?
Usually yes, but very rarely there maybe medical or legal reasons why we cannot share everything with you.
If you would like to know more about how we use your information you can:
- Speak to the person in charge of your care
- Write to Dr Lovis or the Practice Manager who are senior members of staff responsible for confidentiality of patient information at:
- The Wall House Surgery
- The Wall House Surgery
If you wish to see or have a copy of your records you must write to the ‘records manager’ where you are being, or have been treated.
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
The health professionals caring for you keep records about your health and the care you receive.
This information is stored on both paper and computer systems.
Your records include basic details such as your address, ethnic group and next of kin. They also contain facts about your health, including appointments and test results. They may also contain information based on the professional opinion of the staff caring for you.
Your records are used to make sure:
- The staff caring for you have accurate, up to date information to help them decide the best possible care and treatment for you
- 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
- That your concerns can be properly looked into if you have a complaint
- We have an accurate record if we have to review your care.
Your information 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.
If you do not want certain information recorded or used, please talk to the person in charge of your care who can explain what can be done.
If you feel that you are unable to do this, or you are not happy with the outcome, you should write to the chief executive of the trust or the manager of your GP/doctor’s practice.
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.
To make sure you receive all the care and treatment you need we might share relevant information about you with other organisations.
This may include:
- 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 you are unable to consent for any reason, we will only share information where it is clearly in your best interests 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.
We plan services with other organisations outside the NHS. Information shared and used for this does not identify anyone.
Education and Research
Your health record can also help us in:
- Training and educating staff
- Research approved by the Local Research Ethics Committee.
Wherever we can we will remove anything that identifies you. If we cannot, your information will only be used for these purposes when you have given your consent.
You will not be identified in any publication without your consent. If you do not wish to have information used in this way, please talk to the person in charge of your care.
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, for example if you had committed a road traffic offence
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 this is the East Surrey Clinical Commissioning Group 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.
Information held centrally is not used to make any decisions about the treatment or care that you receive from your hospital or your GP.