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What do your medical records consist of?
There are generally three sets of documents, 1) The notes made by a doctor or nurse at
each consultation, 2) Results of tests ordered by your doctor or nurse and done by a
medical laboratory or other hospital department, 3) Correspondence between your doctor
and specialists you may have consulted.
We also record your personal information such as name, address, telephone number, date
of birth, and information relevant to personal medical care such as, ethnic origin,
smoking habits and alcohol consumption. Much of this recorded information is held on a
paper, but more and more medical records are now in electronic format and stored on
computer. If you transfer to another doctor, your records move with you. The computer
information is printed out onto paper and sent along with the rest.
Who has access to your information?
The doctors, nurses and practice manager have unrestricted access to paper and computer
records. Other members of the Primary Care Team (many of whom are not medical) can
access your records on a 'need to know' basis. For instance, if your doctor refers you to a
specialist, he/she will send a letter about your problem. The letter is typed by a medical
secretary who will need to access your records to include the information the doctor has
requested, and be aware of your medical details. If you ring up requesting more
medication that was prescribed a while ago and you are unsure of the name, the clerk
dealing with your request needs to access your records to clarify what is required.
Nobody outside the practice can access personalised information. The Department of
Health or its agents can access non-personalised data directly, and uses this information
to monitor the nation's illness patterns, and smoking and drinking habits for example. We
sometimes send personalised information to other NHS healthcare organisations which
need it. For example, immunization status of children and cervical cytology.
The Department of Health has a commitment to create a central database (so called
'Spine') on every NHS patient. This 'Summary Care Record' can then be accessed by
NHS units in case of medical need (For example Accident and Emergency Departments).
This will require us to send, in due course, essential information from the records we hold
on you, to the 'Spine'. It is planned that patients who object can opt out.
Confidentiality, privacy and security
Every member of staff has a duty to maintain confidentiality. This means that
information we hold about you is only used for the purpose of our medical care of you
and will not be shared with any person who does not need it for that purpose. If you are
over 16 you have these rights. If you are under 16 you may have confidentiality rights in
certain circumstances, but normally parents have the right to information about you.
Privacy, whereby you restrict information to named individuals, is not generally possible
for medical matters as there is a duty on us to share relevant information. Personal non-
medical information can be kept private by stating so to the individual you are telling. No
record would be made if it had no medical relevance. It is worth bearing in mind that it is
normal practice to make full notes in medical consultations of information received and
given.
We keep your paper medical records secure. Computer records are protected by
individual frequently changed passwords and a computer audit trail. Backup and archive
material is kept in a safe.
Can you see your medical records?
Yes. You will normally see your medical records on screen at a consultation. If you wish
to see all or some other part of your records for a particular purpose, you should state that
to a doctor he/she will go through what you need to see with you, probably at a separate
appointment. A charge of £10 is made for a viewing unless the record was made in the
previous 40 days, in which case it is free. If you require a copy of part of your records,
this can be done for a fee of £10 if it is a computer held record. If it is a paper record, or
computer and paper, then there is a charge up to a maximum of £50 to cover costs.
Although NHS records are about you, they remain the property of the NHS so you cannot
take charge of them yourself. And although you are entitled to see any part of your
medical record, there has to be a valid reason. No third party can see your records unless
you give signed consent. We would not release any such information without seeing that
consent ourselves.
Related pages
Confidentiality notice confidentiality issues
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