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 Old Catton Medical Practice


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Records

About health records

EVERYONE WORKING IN THE NATIONAL HEALTH SERVICE HAS A LEGAL DUTY

TO KEEP INFORMATION ABOUT YOU CONFIDENTIAL.


ANYONE WHO RECEIVES INFORMATION FROM US IS ALSO

UNDER A LEGAL DUTY TO KEEP IT CONFIDENTIAL.


Health records play an important role in modern healthcare. They have two main functions, which are described as either primary or secondary.  

Primary function of health records

The primary function of healthcare records is to record important clinical information, which may need to be accessed by the healthcare professionals involved in your care.

Information contained in health records includes:

  • the treatments you have received,
  • whether you have any allergies, 
  • whether you're currently taking medication,
  • whether you have previously had any adverse reactions to certain medications, 
  • whether you have any chronic (long-lasting) health conditions, such as diabetes or asthma,
  • the results of any health tests you have had, such as blood pressure tests, 
  • any lifestyle information that may be clinically relevant, such as whether you smoke, and 
  • personal information, such as your age and address.   

Secondary function of health records

Health records can be used to improve public health and the services provided by the NHS, such as treatments for cancer or diabetes. Health records can also be used:

  • to determine how well a particular hospital or specialist unit is performing, 
  • to track the spread of, or risk factors for, a particular disease (epidemiology), and 
  • in clinical research, to determine whether certain treatments are more effective than others.

When health records are used in this way, your personal details are not given to the people who are carrying out the research. Only the relevant clinical data is given, for example the number of people who were admitted to hospital every year due to a heart attack. 

 

Risk stratification

Risk Stratification is a process that helps us you manage your health. By using selected information from your health records, including from NHS Trusts and our GP practice, a secure NHS computer system looks at recent treatments you have had in hospital or in the surgery and any existing health conditions that you have. This will help your doctor judge if you are likely to need more support and care from time to time. The team at the practice will use this information to help you get early care and treatment where it is needed.

Risk stratification is used in the NHS to

  • help decide if a patient is at greater risk of suffering a particular condition
  • prevent an emergency admission to hospital
  • identify if a patient needs medical help to prevent a health condition from getting worse.

The information will only be seen by qualified health workers involved in your care. NHS security systems will protect your health information and maintain confidentiality at all times. We will only use data which does not identify individuals. Where it is not possible to use completely anonymous data, non-identifiable information such as your NHS Number will be used instead.

 

Our Clinical Commissioning Group carries out this work via a contract with the North East London (NHS) Commissioning Support Unit which has been granted a legal basis for processing data in this way and which operates under strict controls to prevent your information from being re-identified.

 

Should you have any concerns about how your information is managed at the surgery or if you wish to opt out please contact the Practice Manager to discuss how the disclosure of your personal information can be limited.

Types of health record

Health records take many forms and can be on paper or electronic. Different types of health record include:

  • consultation notes, which your GP takes during an appointment, 
  • hospital admission records, including the reason you were admitted to hospital,
  • the treatment you will receive and any other relevant clinical and personal information,
  • hospital discharge records, which will include the results of treatment and whether any follow-up appointments or care are required,
  • test results, 
  • X-rays, 
  • photographs, and 
  • image slides, such as those produced by a magnetic resonance imaging (MRI) or computerised tomography (CT) scanner.  

Confidentiality of your health records

There are strict laws and regulations to ensure that your health records are kept confidential and can only be accessed by health professionals directly involved in your care.

There are a number of different laws that relate to health records. The two most important laws are:

  • Data Protection Act (1998), and 
  • Human Rights Act (1998).

Under the terms of the Data Protection Act (1998), organisations such as the NHS must ensure that any personal information it gathers in the course of its work is:

  • only used for the stated purpose of gathering the information (which in this case would be to ensure that you receive a good standard of healthcare), and 
  • kept secure.

It is a criminal offence to breach the Data Protection Act (1998) and doing so can result in imprisonment.

The Human Rights Act (1998) also states that everyone has the right to have their private life respected. This includes the right to keep your health records confidential. 

Summary Care Record

A Summary Care Record is an electronic record that's stored at a central location. As the name suggests, the record will not contain detailed information about your medical history, but will only contain important health information, such as:

  • whether you're taking any prescription medication 
  • whether you have any allergies
  • whether you've previously had a bad reaction to any medication 

Access to your Summary Care Record will be strictly controlled. The only people who can see the information will be healthcare staff directly involved in your care who have a special smartcard and access number (like a chip-and-pin credit card).

 

Healthcare staff will ask your permission every time they need to look at your Summary Care Record. If they cannot ask you, e.g. because you're unconscious, healthcare staff may look at your record without asking you. If they have to do this, they will make a note on your record.

 

For more information about summary Care Records you can visit www.nhscarerecords.nhs.uk or phone the Health and Social Care Information Centre on 0300 303 5678

 

Freedom of Information

The Freedom of Information Act obliges General Practices to respond to requests for information held by them.  The rights of the public to access this information are subject to some exemptions which have to be taken into consideration before deciding what information can be released.  Under the Data Protection Act patients are also entitled to access their clinical records and should write to Matthew Catley, Practice Manager, Old Catton Medical Practice, 55 Lodge Lane, Old Catton, Norwich, Norfolk, NR6 7HQ. All requests for information must be responded to within 20 working days. 

Much of the information available is free of charge and already on this website.  In some cases there will be charges made to cover the cost of copying, printing, postage and administrative costs.  The current rate of photocopying and or/printing is 30 pence per sheet and the administrative charge is set at £10.00.  These charges will be reviewed regularly.

The practice is not obliged to comply with vexatious requests or repeated or substantially similar requests from the same person other than at reasonable intervals. There are also exemptions covering personal data, security, formulation of government policy, commercial and individual confidentiality.  A further absolute exemption is where information is accessible by other means or if the information has been provided in confidence.  Other exemptions include information relating to commercial interests and audit functions. Information covered by this scheme is only about the primary, general or personal medical services we provide under contract to the National Health Service.


 

 


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