Health Records & Information
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.
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
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.
Important changes – The NHS is currently making some important changes to how it will store and use health records over the next few years.
Summary Care Records
Today, records are kept in all the places where you receive care. These places can usually only share information from your records by letter, email, or phone. At times, this can slow down treatment and sometimes make it hard to access information.
Summary Care Records were introduced to improve the safety and quality of patient care. Because the Summary Care Record is an electronic record, it gives healthcare staff faster, easier access to essential information about you, and help to give you safe treatment during an emergency or when your GP surgery is closed.
For example, a person who lives in London is on holiday in Brighton. One evening, they’re knocked unconscious in a car accident and taken to an accident and emergency (A&E) department. Under the current system of storing health records, it would be difficult for A&E staff to find out whether there are any important factors to consider when treating the person (such as any serious allergies to medications), especially as their GP surgery is likely to be closed. If healthcare staff cannot get the relevant health information quickly, some patients may be at risk.
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.
Do I have to have a Summary Care Record?
You can choose to have a Summary Care Record. If you would like one, you won’t need to do anything. It will happen automatically.
You can choose not to have a Summary Care Record. Let your GP practice know by filling in and returning an OPT-OUT FORM (PDF).
More information about Summary Care Records Download SCR Patient Leaflet or SCR Leaflet
For further information visit:
Local Care Record
This initiative, backed by all local partners, enables real time sharing and viewing of patient information between local hospital trusts and GP Practices across Southwark and Lambeth. It has the potential to deliver a huge range of benefits to professionals and patients. In your GP practice:
Your healthcare history
GPs and practice nurses collect and hold information that includes information about you, your health and the treatment and advice the doctor or nurse provide. Sometimes they record information about your home life and family if it is relevant to your health and healthcare management. Your GP practice also holds the information that is sent to them from other health services such as hospitals.
Staff working in the same practice
Within the practice, the practice team divide roles and responsibilities between them. This means it is likely members of the team, other than your doctor or nurse, may see your information in the course of their work. All of our staff are trained to handle your information properly and work according to the Data Protection Act.
Planning for future health needs
GP practices in Southwark are taking part in a new NHS service that helps your GP to spot whether you need more help to manage your health. The service is called “risk profiling”. Risk profiling will allow your practice to search all of its patients’ records to identify patients that would most benefit from particular care or treatment.
The information will be seen only by qualified health workers involved in your care. NHS security systems will protect your health information and patient confidentiality at all times. If you don’t want your information being used in this way, or have any other concerns, please speak to your GP.
Become better connected with your GP
GP practices would like to improve how they communicate with you. If you provide them with your home telephone number, mobile phone number or email address, they may call, text or email you.
For further information:
How GP Practice’s Share Information
Prospective/future record access
Prospective/future records access means access to information and data added to the patient record from a set date (6 Sept 2023) onwards.
Go Live Date: 6 Sept 2023
You may have read on this website or heard in the media about Prospective/future record access. This refers to a plan to provide patients with online accounts, who do not already have access, with digital access to their medical records from the end of November 2022 (subsequently deferred). The access is to all areas of your medical record, including documents and test results (once they have been assessed and filed by your practice). This applies to Patient Access, as well as the NHS App and other online services providers.
The reason for the change is that evidence has demonstrated that better access to health information enables patients to become partners in managing their health and long-term conditions.
This is an NHS England programme supported by NHS Digital.
The change, when enabled, will not affect:
- Those under the age of 16
- Proxy accounts
Some information may be restricted from a minority of patients due to safeguarding concerns. Your GP practice manages your online access to your medical record. Upon reviewing your records:
- You think that there is any missing information
- You had access to your medical records before the change and can now see less information
- You have any other concerns
The General Data Protection Regulations (GDPR) and the Data Protection Act 2018 state that an individual has the ‘right to be forgotten’, which is sometimes called the ‘right to erasure’, however medical records are slightly different in that they hold special category data. The GP’s (or other clinician’s) opinion at the time will not alter, therefore we cannot remove information simply at the patient’s request.
In line with the General Medical Council’s (GMC) guidance, Doctors have an obligation to:
· Keep clear, accurate and legible records.
· Make records at the time the events happen, or as soon as possible afterwards.
Source: https://www.gmc-uk.org/-/media/documents/good-medical-practice—english-20200128_pdf-51527435.pdf
The NHS constitution states that as a patient, “You have the right to have any factual inaccuracies in your health record corrected, however there are limited exceptions to this right, there is no obligation to amend something in a health record that is a professional opinion”, i.e. the GP’s opinion at the time.
This also applies to data that forms part of your medical record, for example letters and forms issued by other Healthcare organisations involved in your care that have supplied copies to us as your General Practice/registered GP. Data on your record is only to be used in relation to direct care purposes, and if considered to be used for anything else, it would need to have the relevant lawful basis and other data protection principles applied.
Should you request any corrections or redactions we will review your request and if we decide we are not able to comply we will inform you of this decision. We will also ensure we add details of your request to your record and the reasons why we have not been able to comply. Please make any such requests in writing via our website.
Understanding your Health Record
You can view some commonly used abbreviations here, which may help you understand your records.
Whilst we will endeavour to respond to any queries about your records, please bear in mind that we must prioritise our workload and deal with patients that are unwell and need us. Please do not use appointments purely to request something is removed from or changed within your notes. As above, please contact us in writing, using the Contact Us Form on the website and we will liaise with the clinical team and respond within an appropriate time frame – as with most administrative requests this can be up to 28 days.
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Online Services
What is it?
This is a way you can view your GP medical record over the internet from a PC or an App such as the NHS App – free of charge.
Your practice is offering you the opportunity to use the internet to securely view the electronic medical information held about you in a way that is easy to navigate and offers you really useful links to approved resources such as patient information leaflets about diseases, tests, investigations, support groups and medications etc. There are also links to websites such as Patient.co.uk where you can find additional information to help you understand and educate yourself about what you read in your health record.
What are the advantages for me?
If you are waiting for results you will see them as soon as they are added to your record and you will not have to ring the surgery.
You can choose to share your records with those treating you anywhere in the NHS, and anywhere in the world. You may also wish to share your records with family members
You can look up your list of immunisations
Accessing your online record will help you to understand and make use of the information in your records
Access can lead to discussions with your health professionals and helps encourage a more open and honest relationship
What can I see on the Online Medical Record viewing system?
The system allows you to view the following areas of your medical record:
A summary that gives you the most important and recent entries in your health record.
Consultations including: date, practitioner seen, reason for visit, history, examination, outcome, investigations, etc.
- Medical Record showing diagnoses, investigations, and procedures
- Patient Information Leaflets linked from the diagnoses in the medical record section.
- Results showing all investigations such as blood results, liver tests, blood pressure etc.
- Letters to and from the GP.
Under The Data Protection Act 1998 your practice may refuse access to all or part of your health records.
What are the risks for me?
There may be something in your record that you do not want to be reminded about.
Some terms may be difficult to understand as the notes are made by doctors and nurses for each other. There will be links to explanations to help you.
Test results that are abnormal and posted say, on a Friday, may worry you over the weekend if you cannot see the doctor or nurse to discuss them.
Can I view my child’s record?
Most practices allow parents to access their child’s records up until they are 12 years old. Should you wish to access your child’s records beyond their twelfth birthday you need to discuss this with your practice
Can I alter the record?
No. This is a ‘read only’ facility. You can however, print off details to take to e.g. a hospital appointment. If you think that there is something that needs to be changed, you will need to contact the surgery.
What about security?
Record access has the same level security as online banking. A hacker would only be able to see one page at a time. Nothing changes with the way your medical information is stored.
Your information will remain under the control of your GP as it does now. And like online banking you control viewing by using your PIN and pass words. You will be responsible for keeping your log in details safe.
Logging off or a power failure will clear all the information on your computer system.
Will my data be sold on to private health companies?
The Data Protection Act (1988) states that data which identifies you can only be used with your explicit permission.
What if I don’t want to register to use this System?
If you do not want to register to use this system you can still use all the practices’ services exactly as before.
Your decision not to register will not affect your treatment or your relationship with your GP practice in any way.
Download the Leaflet and Form from link: Online Services Records Access Patient Information Leaflet and Form
How we Use Your Information:
Please Click and Download A Full Copy Here: How We Use Your Information
Privacy Information Leaflet – What is a privacy notice?
A privacy notice helps your doctor’s surgery tell you how it uses information it has about you, like your name, address, date of birth and all of the notes the doctor or nurse makes about you in your healthcare record.
Why do we need one?
Your doctor’s surgery needs a privacy notice to make sure it meets the legal requirements which are written in a new document called the General Data Protection Regulation (or GDPR for short).
What is GDPR?
The GDPR is a new document that helps your doctor’s surgery keep the information about you secure. It’s was introduced in May 2018, making sure that your doctor, nurse and any other staff at the practice follow the rules and keep your information safe.
For Privacy Notice please download copy from the link: Privacy Notice
Please Click Here: GDPR Child Friendly Poster
Please Click Here for Privacy Notice of : Southeast London ICB
Under data protection law we must tell you about how we use your personal information. This includes the personal information that we share with other organisations and why we do so. Our main GP practice privacy notice is above. This additional privacy notice provides details about the personal information that we are sharing with NHS Digital for its General Practice Data for Planning and Research data collection: Click Here
Your NHS Data Matters
Use this service to request that your confidential patient information is not used beyond your own individual care.
If you decide to opt out, this will be respected and applied by NHS Digital and Public Health England. These organisations collect, process and release health and adult social care data on a national basis. Your decision will also be respected and applied by all other organisations that are responsible for health and care information.
An opt-out will only apply to the health and care system in England. This does not apply to your health data where you have accessed health or care services outside of England, such as in Scotland and Wales.
If you choose to opt out, your data may still be used during some specific situations. For example, during an epidemic where there might be a risk to other people’s health.
Under data protection law we must tell you about how we use your personal information. This includes the personal information that we share with other organisations and why we do so. Our main GP practice privacy notice is above. This additional privacy notice provides details about the personal information that we are sharing with NHS Digital for its General Practice Data for Planning and Research data collection: Click Here
Opting out of sharing your confidential patient information – Your Choices.
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For further information:
