Clinical Records

How we use your Medical Records

We need to keep records so that we can deliver your clinical care effectively, but your records may also be used outside the practice in the circumstances mentioned below.

There are two broad areas where your records are used

Where the NHS needs to know about the effectiveness of its delivery of services.Service Delivery monitoring
Where there is a Clinical need. Clinical Need

Service Delivery Monitoring

This has become a requirement from 2014

In order for the NHS to monitor the effectiveness of service delivery, cost effectiveness and audit, it is necessary to collect your data for this purpose. In this regards the data obtained is annonomised so that you cannot be identified personally. Neverhteless you still have the option of opting out but you need to contact us as indicated below. The default possition is that you are opted in.

If you do not want your data to be shared outside your GP practice please contact the receptionists who will update your medical record with a code stating your dissent of disclosure.

If you are happy for your informaiton to be shared you do not need to do anything further.

Full information is available here or you can contact the patient information line on 0300 456 3531.

Clinical Need

In order to deliver quality care the NHS needs to keep records about your medical care. Below is a summary from an NHS booklet entitled The Care Record Guarantee, which encompasses the record keeping by all NHS organisations including your general practitioner records.
The people who care for you use your records to:-

provide a good basis for all health decisions made by you and your care professionals
allow you to work with those providing care
make sure that your care is safe and effective
work effectively with others providing you with care

Others may also need to use your records to:-

check the quality of care (such as a clinical audit)
protect the health of the general public
keep track of NHS spending
manage the health service
help investigate any concerns or complaints you or your family may have about your health care
teach health care workers
help with research

You have the right to:-

confidentiality under the Data Protection Act 1998, the Human Rights Act 1988 and the common law of duty of confidence (The Disability Discrimination Act and the Race Relations Act may also apply)
to ask for copies of all your records about you. Applications for access to your records must be made in writing to the operational manager. A fee is payable for this service. Third party access is only given by signed consent by the patient. This ensures your confidentiality.

We have a duty to:-

maintain full and accurate records of the care we provide to you
keep records about you confidential, secure and accurate
provide information that is in a format that is accessible to you (e.g. large print if you have sight problems)

We have a legal duty to give information about people under certain circumstances. Examples include:-

Births of Children
Reporting of some infectious diseases. (Called Notifiable Diseases)
Serious Crime
To protect children
If we receive a court order to divulge information

Permission to share information is given by the senior clinician in charge of protecting privacy in the practice, and has the title of Caldicott Guardian.

More information can be obtained from Care Record Development Board

Allowing us to share some of your personal medical information will ensure better health care outside of your GP practice.

Clinical Commissioning Groups are working together with our health care providers across East Lancashire.

Doctors, nurses and other health care professionals rely on good communication with their patients – and each other – to provide top-quality care. As part of our continual approach to improving the service you receive we aim to improve communication with a new way to share vital, personal medical information.

In the past, there has been no way for a healthcare professional working in Accident and Emergency (A &E), an out-of-hours GP or any other doctor or nurse outside of a GP practice involved in caring for you, to know about ongoing medical conditions you have, or even what medication you are taking.

They simply have had to take the patients word for it – and patients needing treatment can be confused, in pain or unconscious. Blackburn with Darwen and East Lancashire GPs and the Clinical Commissioning Group are working with local NHS care providers to implement a scheme allowing doctors and nurses in various care settings, including A &E and out-of-hours surgeries, to view restricted but vital information held on a GP practice’s computer system. This could include medication lists, important allergies and major illnesses.

Are my records treated in confidence?

Patient safety and confidentiality are our most important concerns and patients can choose not to allow a doctor or nurse to see their medical record by saying ‘no’ when their permission is requested. You can also opt out of sharing any information with anybody outside your own GP practice at any time. If you need further help please discuss this with your GP.

What safeguards do you take?

Both you and your GP practice will need to give consent for this information sharing to occur. Only health care workers actively involved in your care can see your medical record summary and only for a limited time. You will be asked for consent to do this at every consultation. Every care is being taken to protect your confidentiality and all information is stored securely.

The future

In time, the computer technology used here could be rolled-out across wider parts of the NHS in East Lancashire, allowing other community health care staff, such as District Nurses and hospital doctors, secure access to the medical records of the patients in their care and allowing more services to be delivered in the community, closer to patients homes.

You will usually be asked for your permission before this happens (unless you are unconscious).

Can I opt out?

Yes. Remember, you can opt out of sharing any of your medical information with local health care staff. Please speak to your GP if you have concerns.