When you see the doctor or nurse the information obtained from talking to and examining you is recorded on the practice computer in your medical record.
This policy is based on guidance from the General Medical Council, Royal College of General Practitioners and the Department of Health. The standard of the doctors’ record keeping is internally audited at regular intervals to ensure high standards are being maintained.
Confidentiality
The practice complies with Data Protection and access to medical records legislation.
Identifiable information about you will be shared with others in the following circumstances:
- To provide further medical treatment for you e.g. from district nurses and hospital services
- To help you get other services e.g. from the social work department. This requires your consent
- When we have a duty to others e.g. in child protection cases
- Anonymised patient information will also be used at local and national level to help Southern Derbyshire Clinical Commissioning Group and Department of Health plan services e.g. for diabetic care
If you do not wish anonymous information about you to be used in such a way, please let us know.
Reception and administration staff require access to your medical records in order to do their jobs. All staff in the practice are contractually bound to maintain patient confidentiality and any proven breach of this will be treated extremely seriously.
We respect your right to privacy and keep all your health information confidential and secure. Confidentiality extends also to patients’ family members. Medical information relating to you will not be divulged to a family member or anyone else, without your written consent.
As we are a computerised practice, all our patient records are kept on computer, and can assure patients of complete confidentiality.
Your rights are protected as we are registered under the Data Protection Act 1998.
It is important that the NHS keeps accurate and up to date records about your health and treatment so that those treating you can give you the best possible advice and care. However, for the effective functioning or our multi disciplinary team it is sometimes necessary that medical information about you is shared between members of the practice team.
Your rights in relation to disclosure of such information are covered by the practice’s registration under the Data Protection Act and we follow the guidance issued by the General Medical Council in ‘Confidentiality: Protecting and providing Information’ which explains circumstances in which information may be disclosed.
This information is only available to those involved in your care and you should never be asked for personal medical information by anyone not involved in your care.
You have a right to know what information we hold about you. If you would like to see your records, please contact the practice manager.
How the practice uses personal health information
Access to the whole clinical computer system is gained only by individual passwords.
All personal health information is recorded onto your computerised record, all entry is by password, each user having their own individual password changed on a regular basis.
The surgery is registered under the Data Protection Act and all stored information is strictly confidential just as the information in your traditional handwritten records. Any information requested by a third party (e.g. insurance companies) will not be released until we have obtained your written consent. You have the right to read any report about you to a third party before it is sent.
If you do not wish your medical records to be on the National Spine database for sharing medical information between GP practices and hospitals you must inform the practice in writing.