Confidentiality & Medical Records
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 the Health Board and Government 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. These members of staff are bound by the same rules of confidentiality as the medical staff.
Freedom of Information
Information about the General Practioners and the practice required for disclosure under this act can be made available to the public. All requests for such information should be made to the practice manager.
Access to Records
In accordance with the Data Protection Act 1998 and Access to Health Records Act, patients may request to see their medical records. Such requests should be made through the practice manager and may be subject to an administration charge. No information will be released without the patient consent unless we are legally obliged to do so.
We make every effort to give the best service possible to everyone who attends our practice.
However, we are aware that things can go wrong resulting in a patient feeling that they have a genuine cause for complaint. If this is so, we would wish for the matter to be settled as quickly, and as amicably, as possible.
To pursue a complaint please contact the practice manager who will deal with your concerns appropriately. Further written information is available regarding the complaints procedure from reception.
The NHS operate a zero tolerance policy with regard to violence and abuse and the practice has the right to remove violent patients from the list with immediate effect in order to safeguard practice staff, patients and other persons. Violence in this context includes actual or threatened physical violence or verbal abuse which leads to fear for a person’s safety. In this situation we will notify the patient in writing of their removal from the list and record in the patient’s medical records the fact of the removal and the circumstances leading to it.
Due to the number of patients failing to attend for their appointment this may mean that you may not be able to see the doctor on the day that you wish to.
In an attempt to try and resolve this the Practice has developed the following policy:
If you fail to attend for 2 consecutive appointments without informing us we will write to you asking if there are any specific problems preventing you from letting us know.
If you fail to attend for a 3rd appointment you may be removed from the practice list and have to find an alternative GP Practice.
Patients and staff need to be confident that best practice is being followed. For certain examinations you will be offered a chaperone which on occasion may mean rebooking your appointment. If you think a chaperone will be required please make this known when you book with reception.
The purpose of this protocol is to set out the Practice’s approach to consent and the way in which the principles of consent will be put into practise.
Where possible, a clinician must be satisfied that a patient understands and consents to a proposed treatment, immunisations or investigation.
Implied consent will be assumed for many routine physical contacts with patients. Where implied consent is to be assumed by the clinician, in all cases, the following will apply:
An explanation will be given to the patient what he/she is about to do and why.
The explanation will be sufficient for the patient to understand the procedure.
In all cases where the patient is under 18 years of age a verbal confirmation of consent will be obtained and briefly entered into the medical record.
Where there is a significant risk to the patient an ‘Expressed Consent’ will be obtained in all cases (see below).
Expressed consent (written or verbal) will be obtained for any procedure which carries a risk that the patient is likely to consider as being substantial. A note will be made in the medical record detailing the discussion about the consent and the risks. A Consent form may be used for the patient to express consent (see below).
Consent (Implied or Expressed) will be obtained prior to the procedure.
The clinician will ensure that the patient is competent to provide a consent (16 years or over) or has ‘Gillick Competence’ if under 16 years (has 'sufficient understanding and maturity to enable them to understand fully what is proposed'). For children under 16 someone with parental responsibility should give consent on the child’s behalf by signing accordingly on the Consent Form.
From time to time we may wish to use video recording as part of doctors' training. This will not be done without patients' consent and will never be used during intimate physical examination. Patients may ask for the video recorder to be turned off at any time during a consultation.
Statement of intent
New contractual requirements came into force from 1st April 2014 requiring that GP practices should enable and promote a range of online patient facilities:
1.Online booking of appointments
2.Online ordering of repeat prescriptions
3.Summary Care Record
5.Patient access to their electronic summary care record
We provide all of the above. Please find below details:
Online booking of appointments
Practices are required to promote and offer to registered patients the facility to book, view, amend, cancel and print appointments online.
Online ordering of repeat prescriptions
Practices are required to promote and offer to registered patients the facility to order repeat prescriptions for drugs, medicines or appliances online; and to view and print a list of any drugs, medicines or appliances in respect of which the patient has a repeat prescription.
Summary Care Record (SCR)
Where there is a change to the information included in a patient’s medical record, practices must enable an automated upload of summary information from its clinical IT system to the Summary Care Record, at least on a daily basis. The summary information will include details of medications, allergies and any adverse reactions to medications. SCRs provide healthcare staff treating patients in an emergency or out-of-hours with faster access to key clinical information.
GP2GP record transfers
There is a contractual requirement to utilise the GP2GP facility for the transfer of patient records between practices, when a patient registers or de-registers.
It is very important that you are registered with a doctor at all times. If you leave your GP and register with a new GP, your medical records will be removed from your previous doctor and forwarded on to your new GP via NHS England. It can take several weeks for your paper records to reach your new surgery. With GP2GP record transfers, your electronic record is transferred to your new practice much sooner.
Patient access to electronic records
Practices are required to promote and offer the facility for registered patients to view online, export or print summary information from their records - relating to medications, allergies, adverse reactions, and any additional data which has been agreed between the clinician and the patient.
Produced 03/02/2015 by Helen Harris (Practice Manager)
Sharing Policy for Children under 5 years - Please be aware that it is the policy of Number 18 Surgery to share the record of all children under the age of 5 years with other healthcare professionals dealing with your child’s/children’s care.