How We Use Your Medical Records - Important Information For Patients
On this page we have tried to include all of the information that you need to know about the data that we keep about you, how you can access it and how you can decide who it is shared with.
There are a number of different NHS schemes involving medical records and we have included information on them all below.
- This practice handles medical records in-line with laws on data protection and confidentiality.
- We share medical records with those who are involved in providing you with care and treatment.
- In some circumstances we will also share medical records for medical research, for example to find out more about why people get ill.
- We share information when the law requires us to do so, for example, to prevent infectious diseases from spreading or to check the care being provided to you is safe.
- You have the right to be given a copy of your medical record.
- You have the right to object to your medical records being shared with those who provide you with care.
- You have the right to object to your information being used for medical research and to plan health services.
- You have the right to have any mistakes corrected and to complain to the Information Commissioner’s Office.
Privacy Notice - Provision Of Direct Patient Care
Privacy Notice - Legal Requirements To Share Data
Privacy Notice - Naional Screening Programmes
Privacy Notice - Medical Reserch And National Clinical Audits
Privacy Notice - Data Protection For Patients
Confidentiality
Patients have an absolute right to the confidentiality of their information, subject only to the requirements of legislation or overriding public interest as defined by case law or GMC guidance. All doctors and staff working at the surgery have a duty to maintain confidentiality at all times. If you have any concerns regarding confidentiality please bring them to our attention by telephone, in writing or by using the contact us tab on our website.
Freedom of Information
The practice has a publication scheme produced in accordance with the Freedom of Information Act. The scheme is available on request to the Administration Manager at Markfield Medical Centre or by using the contact us tab above.
Our Computer System
SystmOne is a computer system that GPs and other people looking after patients can use to record medical information and other relevant information discussed at your time of contact. Not everyone uses this particular system, but many GPs and Community Health services in this area use this system to record patient notes.
What is in my Medical Record?
Your medical record contains notes taken during every consultation you have had with a doctor or nurse at your practice or community service. Your record is also likely to include copies of any letters you have written and notes relating to any phone calls made with the service that you have been in contact with. Your record will also contain copies of letters from other hospitals and departments, including mental health assessments if you have ever had one. The time period covered by your electronic medical record can vary from one GP practice to another, but detailed information extending right the way back into your childhood may be included. All of this information is sometimes known as "Your Detailed Care Record."
How to access your Medical Records
Terms Used in this section
Data Controller - This is the controller of the data and the system, as defined in the Data Protection Act. In this case the Controller is the Partnership.
Data Subject - This is the person whose information is within the system, and who has rights of access as determined under the Act.
Third Party - A person or body other than the Data Subject who requests access, or to whom information may be provided.
Access - Data Subject
The General Data Protection Regulations specify the rights of access of the Data Subject.
All requests for access must be in writing on a Data Access form which will be provided on request.
The form must be fully completed.
A response will be provided as soon as possible, and in any event within 28 days. Where an application is declined, a reason will be given. In some circumstances, some parts of your record may be withheld.
Making an Access Request
Please read the information carefully.
1) Please ask at reception for a telephone call from the Management Team who will ask you to compete a form.
2) Ensure that the form is fully completed, using a separate sheet of paper if necessary, and return it to the practice.
3) There are some circumstances where a fee may be charged and you will be informed if this is the case.
4) Your request will be considered and you will be advised of the decision or provided with the records within 28 days. There is no facility for immediate access.
Subject Access Request Policy And Form
Access to your Medical Records Online
It is now possible to access some elements of your medical records online. For more information please click on the link below. Thank you.
Once you have an account please follow this link.
Choices on how you want us to share your Information
1) The Enhanced Data Sharing Model
The EDSM is designed to make it easier for patients to have greater control over their own records. By recording two different sharing consents in the patient record, 'sharing in' and 'sharing out', the decision not to share sits with the patient. 'Sharing out' controls the information recorded at the practice that is shared to other organisations. 'Sharing in' controls the information that can be viewed by the practice that has been recorded at another SystmOne organisation. The model works on a patient-by-patient basis, which means that if you move to a different area, you will remain on the EDSM model.
At this practice your GP records are made available for other health care professionals involved in your care to access. We feel this is in your best interest. Please be assured that no one outside of this practice will access your records without your verbal consent each time you are seen.
If you do not wish this to happen then it is important that you let us know by telephone, in writing or by using the contact us tab on our website so that we can mark it on your record.
2) Summary Care Record - Version 2 is here!
What is a Summary Care Record? (also know as an SCR)
Your basic Summary Care Record is a short summary of your GP medical record that includes a list of medications you are taking and your allergies or bad reactions to medicines.
Version 2 includes all of the above PLUS additional information that can include information about the management of any Long Term Conditions such as Diabetes, Heart Conditions etc, your relevant medical history including why you take a particular medicine or any clinical procedure you have had, any specific communication needs or preferences about your future care and a list of your Immunisations.
You will already have a basic SCR unless you opted out but you will need to give specific consent for an SCR version 2. If you would like to give consent for the additional information to be added to your SCR please contact our reception team and we will send you a form to consent.
Your SCR can be viewed by other health and care staff who care for you when you are away from home. This can speed up your care and make sure you are given the correct treatment and medication. The healthcare staff will have been given the right levels of security access will always ask your permission to look at your SCR (except in an emergency, where you are unconscious for example).
When an SCR would be useful:
- in an emergency
- when you're on holiday
- when your surgery is closed
- at out-patient clinics
- when you visit a pharmacy
Who would benefit from an SCR with additional information?
- Frail patients who can give consent to out of hours or emergency health care staff, making unwanted admission less likely
- Patients with physical or other disabilities who will benefit from recording any specific communication or health needs
- Patients with carers whose details they want to share
- Non-English speakers
- Patients planning for end of life who can share information about Lasting Power of Attorney or advance care decisions
3) NHS Central Date Collection ( Care.date)
A modern information system has been developed, which will make increased use of information from medical records with the intention of improving health services. The system is being delivered by the Health and Social Care Information Centre (HSCIC) and NHS England on behalf of the NHS.
Your date of birth, full postcode, NHS Number and gender rather than your name will be used to link your records in a secure system, managed by the HSCIC. Once this information has been linked a new record will be created. This new record will not contain information that identifies you. The type of information shared, and how it is shared, is controlled by law and strict confidentiality rules.
If you do not wish this to happen then it is important that you let us know by telephone, in writing or by using the contact us tab on our website so that we can mark it on your record. For more information about this scheme including a downloadable leaflet please follow the link below.
http://www.nhs.uk/NHSEngland/thenhs/records/healthrecords/Pages/care-data.aspx
4) Risk Stratification
What is risk stratification?
There are two kinds of risk stratification:
The first kind is a process for identifying some patients within a Practice who might benefit from extra assessment or support with self-care because of the nature of their health problems. The process is a mixture of analysis of information by computer followed by review of the results by a clinical team at the Practice.
The analysis can, for example, help predict the risk of an unplanned hospital admission so that preventative measures can be taken as early as possible to try and avoid it. In the end, it is the clinical team of the GP Practice that will decide how your care is best managed.
The second kind is a process for identifying patterns of ill health and needs across our local population. This will be done by pulling together all the information in an anonymised file (where your identity has been removed) to look at patterns and trends of illness across Leicester, Leicestershire and Rutland as a whole. This will help our Public Health Department and those in the NHS who are responsible for planning and arranging health services across Leicester, Leicestershire and Rutland (known as commissioners) better understand the current and possible future health needs of the local population. This will help them make provision for the most appropriate health services for the people of this area. This group of staff will not be able to identify you as an individual under any circumstances.
In both cases secure NHS systems and processes will protect your health information and patient confidentiality at all times.
What information about me will be analysed?
The minimum amount of information about you will be used. The information included is:
Age
Gender
GP Practice and Hospital attendances and admissions
Medications prescribed
Medical conditions (in code form) and other things that may affect your health such as height, weight for example.
How will my information be kept secure and confidential?
Information from your GP record will be sent via a secure computer connection to a special location called a ‘safe haven’ at NHS Arden and Greater East Midlands Commissioning Support Unit (NHS Arden & GEM CSU) in Leicester This safe haven carries special accreditation from the NHS. It is designed to protect the confidentiality of your information. There are strict controls in place. It enables information to be used in a way that does not identify you. The GP Practice remains in control your information at all times.
Before any analysis starts, any information that could identify you will be removed and replaced by a number. The analysis is done by computer. The results are returned to the GP Practice. Only your GP Practice can see the results in a way that identifies you.
What will my GP Practice do with the analysis?
The results can help the clinical team decide on some aspects of your future care. For example, if the clinical team at the Practice think that you might benefit from a review of your care, they can arrange this. You may then be invited in for an appointment to discuss your health and treatment. If the Practice thinks you might benefit from referral to a new service, this will be discussed with you firstly.
What should I do if I have further questions about risk stratification?
Please ask the Practice staff if you can speak to someone in more detail.
What if I want to opt out?
If you do not wish this to happen then it is important that you let us know by telephone, in writing or by using the contact us tab on our website so that we can mark it on your record.
5) Leicestershire MIG
Health services in Leicester, Leicestershire and Rutland are introducing a new system of sharing medical records between a GP practice and other NHS organisations.
The system will allow the healthcare professional who provide you with care, to view information in your GP medical record. Viewing your record will help to improve the quality of your care and potentially save lives.
Who will be able to view my medical record and what will they use it for?
A qualified healthcare professional who has obtained your consent will be able to view your GP medical record. This will only ever be done for the specific problem you are presenting with. This will allow the clinician assessing you to have faster, easier access to relevant information about you, to help provide you with safer and better care.
Currently the following organisations are taking part, but as more organisations sign-up, this list will change. Please ask at reception for for more up-to-date information:
- University Hospitals of Leicester NHS Trust
- Leicestershire Partnership NHS Trust
- Northern Doctors Urgent Care Ltd
- Oadby and Wigston Walk-in Medical Centre
- Melton Mowbray Hospital Minor Injury and Illness Service
- Market Harborough Minor Injury and Illness Unit
- Rutland Memorial Hospital Minor Injury and Illness Unit
- Derbyshire Health United – NHS 111
- Urgent Care Centre, Loughborough
- Out of Hours Services
- East Midlands Ambulance Service NHS Trust
- George Eliot Hospital NHS Trust – Urgent Care Centre Leicester
- SSAFA Acute Visiting Services
What information can be viewed?
- personal information, such as name, date of birth, gender
- allergies
- medication
- attendances, hospital admission and referral dates
- vaccinations and immunisations
- test results, including measurements such as blood pressure
- diagnoses (current and post problems)
- treatment and medical procedures
What will happen when the healthcare professionals want to view my GP medical record?
You will be asked directly to give your explicit consent, at the point of contact, for your GP medical record to be viewed. You can say yes or no; the Consultant/Doctor will only view your record if you say yes.
You will be asked beforehand for permission by the assessing healthcare professional each time your medical record is viewed. Your healthcare professional is only viewing your record. They are not downloading and storing any of your data. This means that when they close your record it is no longer accessible outside of your surgery.
If you are unable to give consent, for example if you are unconscious and it is deemed to be vital for your survival, then a healthcare professional may view your GP medical record in order to be able to provide appropriate care for you.
If I give permission to view my GP medical record, how long does this permission last?
Your GP medical record will only be viewed while you are currently being treated. When you are discharged back to the care of your GP, electronic access to your medical record will stop until someone asks you again.
Can I refuse to allow my GP to share my medical record?
If you are concerned about sharing your GP medical record you can opt out of allowing it to be shared. If you do not wish for your information, or even part of it, to leave your GP practice clinical system then please ask at the reception who will be able to arrange this for you.
Can I change my mind?
Yes you can change your mind about opting-in or opting-out at any time by asking to speak to the Practice Business Manager.
How will my information be kept secure and confidential?
A secure system will be used to allow access to your GP Practice System by another organisation. All organisations involved must sign an Agreement to confirm that they will adhere to the strict controls in place around the computer system itself and around any staff who are allowed to access the system. Everyone working for the NHS has a legal and contractual duty to keep information about you secure and confidential.
How can I find out who has viewed my GP medical record
Every time your GP record is accessed by another organisation, a message is sent back to your GP Practice system and stored in an audit log
Is there a danger someone else could hack into my record or that my information could be lost?
The NHS has the strongest security measures available and there is strong protection to prevent any information from being accessed without permission. As the organisations are only viewing your record, it is not possible for them to delete any information or for it to be lost.
