Why we collect information about you and what records do we keep
To provide you with the best quality care possible, we must keep health records about you. These contain information about the treatment and support you receive which is recorded by the professionals who have been involved in your care.
This may include:
- Basic details about you such as address, date of birth, next of kin;
- Any contact we have had with you such as clinical visits;
- Notes and reports about your health;
- Details and records about your treatment and care;
- Hospital letters;
- Results of x-rays, laboratory tests etc.;
- Any other relevant information from people who care for you and know you well such as health professionals and relatives.
How we keep your records confidential
Everyone working for the NHS has a legal duty to keep information about you confidential and secure. To help us protect your confidentiality, it is important to inform us about any relevant changes that we should know about, such as change of address, telephone, change of personal circumstance.
All staff working in the practice sign a confidentiality agreement that explicitly makes clear their duties in relation to personal health information and the consequences of breaching that duty.
Access to patient records by staff other than clinical staff is regulated to ensure they are only accessed when there is a genuine need to do so, such as when identifying and printing repeat prescriptions for patients, or when typing referral letters to hospital consultants.
How your information may be used
We will share information in your health record o allow health professionals to work together more effectively to ensure you receive the best quality care. You may choose not to share your information by completing the form at the end of this leaflet.
Summary Care Record
One of the ways of sharing your health information for your care is through the Summary Care Record (SCR). The SCR is available nationally to health professionals who may care for you. It contains important information about any medicines you are taking, any allergies you suffer from, and any bad reactions to medicines that you have had. Access to this information can prevent mistakes from being made when caring for you in an emergency, or when your GP practice is closed.
You can also ask for your SCR to include additional information about you, such as your current health conditions. This is known as an Enriched SCR. We will only add information to your SCR with your consent; please complete the form at the end of this leaflet to let us know whether or not you would like a SCR.
Further information on the SCR can be viewed at: https://www.digital.nhs.uk/summary-care-records.
SystmOne – GP Clinical System
Another way of sharing your information for your care is through the confidential electronic record system that we use in our practice, called SystmOne. This is used widely across the NHS and care organisations to keep accurate medical records about you. These records store important information about your illnesses and the care you have received in the past. Your record may contain information from different health and social care organisations such as a hospital, a minor injuries unit, or from a community care service such as district nursing.
Organisations can only access your medical record if you give them permission. For example, you may be working or on holiday in another part of the country and need care from a hospital or a clinic. Having access to your whole medical record will improve the care they can provide you.
How does this work?
You will need to give us your preferred mobile phone number or email address, which we will record on your medical record. This means that when another organisation asks to access your record, we can send you a verification (security code) which allows you to choose whether to let that organisation view your medical record or not.
If you already use the SystmOnline patient portal, then you can select organisations to allow or prevent them from accessing your records. If you do not have a phone or email address and don’t use SystmOnline, then we will be happy to record your choices about which organisations you are happy to share your whole record with. When you receive care from organisations close to your home (Dorset), you will not usually need to give a verification (security) code because we work regularly with these organisations.
However, you should still be asked for your consent to share. Further information about SystmOnline and these sharing controls, can be viewed at: https://systmonline.tpp-uk.com/2/help/help.html.
Can I ask for my information not to be shared?
Organisations using SystmOne should only access your record when they are involved in giving you care. Whenever a professional from another organisation wishes to view your record, they will always ask for your consent. If you choose not to allow them to access your record, they will not be able to see any information. However, you should be aware that this could disrupt your care.
If you are a carer and have a Lasting Power of Attorney for health and welfare then you can decline on behalf of the patient who lacks capacity. If you do not hold a Lasting Power of Attorney then you can raise your specific concerns with the patient’s doctor.
If you have parental responsibility and your child is not able to make an informed decision for themselves, then you can make a decision about information sharing on behalf of your child. If your child is competent then this must be their decision.
Can I change my mind?
You may also change your mind about sharing at any time. We aim to ensure that your choices about how your information is shared are respected.
Can I access my records?
The Data Protection Act 1998 (DPA) and the General Data Protection Regulation (replaces the DPA from 25 May 2018) gives every living person, or authorised representative, the right to apply for access to their health records. You have a right to ask for a copy of all records held about you.
An audit log is maintained showing who has accessed your record, and when. You are also entitled to request a copy of this log. You can view your own health record, change how your record is accessed, and view an audit trail of who has accessed your record by using the SystmOnline patient portal. Ask your practice for details on how to set up an online account.
If you think that anything in your record is factually inaccurate or incorrect, or would like any further detail about your information rights under the General Data Protection Regulation, please inform us.
Can anyone else see my medical records?
We will not share your medical records without your consent, unless we are required to share them for legal reasons. For example, occasionally we may receive requests from insurance companies to have copies of your medical records. We will ask for your signed consent before releasing these, unless we have received a court order requesting this information.
However, we may also need to provide limited information to local authorities about some infectious diseases or if you have had food poisoning. We would not require your consent to do this.
Very rarely, doctors may be required to disclose information in order to detect a serious crime. Likewise, a court order can require doctors to disclose certain information during a court case.
What do I need to do now?
Please contact reception if you have any further queries on how we use and share your information.