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Your Medical Records, Dolphins Practice, Haywards HeathYou, Your rights and Your Health Record

This page explains how we use and safeguard information collected about you and your healthcare. It outlines who may have access to the information and how you can arrange to see it.

This information may be stored either on computer or in manual records. It is kept to ensure that you receive the best possible care, both now and in the future.

How do we keep your information secure and confidential?

We take security and confidentiality very seriously. Staff are required to abide by strict codes of conduct and participate in regular training.

Everyone working for the Dolphins Practice has a legal duty to keep information about you confidential. This means that we must share information only with those who have a genuine need to know it. This may include people who provide care to you from other organisations as well as the medical practice. They too have a legal duty to keep information confidential.

How is your information used?

The main purpose is to provide your healthcare and treatment. People who may see the information include:

  • Members of the healthcare team, e.g. doctors, nurses, Healthcare Assistants and therapists
  • Administrative staff supporting the healthcare team e.g. medical secretaries

If you agree, your relatives, friends and carers will be kept up to date with the progress of your treatment.

Your information will also be used for other NHS purposes and passed to other organisations so we can all work together for your benefit. The sharing of information is strictly controlled and wherever possible we will remove details that identify you.

Uses of your information will include:

  • Teaching and training healthcare staff
  • Helping staff to review the care they give, to make sure it is of the highest standard>
  • Reviewing and planning services to meet the needs of patients. This includes sending information to Health Authorities and the Department of Health
  • Helping with research into better methods of healthcare. The Local Research Ethics Committee must approve research projects. In certain circumstances we will need to ask for your permission to use information about you.

In some situations we have a legal duty to report information to the appropriate authorities, for example: Reporting of certain infectious diseases that might seriously affect the health of other people. e.g. meningitis or measles, but not HIV or AIDS or where a formal court order has been issued.

How can you see the information we hold about you?

The Data Protection Act 1998 gives service users the right of access to their own records, held either on computer or on paper.

  • If you are receiving treatment you may arrange to discuss your records informally with your doctor or other healthcare professional.
  • When we receive a written request we will send you a form, for you to give us further details and proof of identity.
  • We are then required to give you access to your record within 40 days of receiving your completed form.
  • We have a duty to make any medical or technical terms in your record understandable to you. You may wish to make an appointment to discuss anything you do not understand.
  • If you think there is a mistake in your records, you should write to tell us, so that an amendment can be added to your records.
  • In exceptional cases, information from your record may be withheld if your healthcare professional believes it is likely to cause serious harm to your mental or physical health.
  • Information may also be removed if it identifies a third party or has been provided by a third party and we do not have their consent to disclose it.
  • If you are asking to see the records of a service user who has died, under the Access to Health Records Act 1990 you will need to prove that you are the users legal personal representative or that you have a claim resulting from the death.

Can you see your child's record?

Yes, if you have legal parental responsibility. Your child must understand and consent to your request. If your child is too young to give consent, you can obtain access to his/her record if we are satisfied that access is in the child's best interest. Children can apply to see their own health records. A request from a child will be considered if we can be satisfied that the child can fully understand the information held.

Can somebody else see your record?

Yes. The person applying must have written authorisation from you. If you become incapable of giving authorisation, the person appointed by a court to manage your affairs must give it.

Will we charge you to see the records?

If you wish to look at your paper/computer records then a charge of £10 will be made.

  • If you wish to be given copies of your records a charge of £50 will be made.
  • Please note that you will need to pay any charges before you can see your records.

The NHS Care Records System and the 'Big Opt Out'

The Department of Health is hoping, at some point in time, to transfer the medical records of everyone to a centrally held, government controlled database called the NHS Care Records System or NHS "spine". This will make a patients' entire medical records potentially viewable to anyone working within the NHS.

Your data will be available, without your consent and in an identifiable way, to thousands of non–clinical health administrators.
The Department of Health wants patients' medical records to be uploaded by default, unless the patient actively objects – an "opt out" mechanism: that is, if you do and say nothing, your notes will be uploaded. The British Medical Association, as well as many GPs, do not support presumed consent but strongly believes that patients should be asked to give informed, explicit consent before their health records are placed on a national database, i.e. an "opt in" mechanism: your notes should remain with your GP until such time as you indicate that you actively wish for them to be uploaded (if ever).

Many GPs would prefer not to accept an "opt out" mechanism for such a sensitive action. Government cannot upload data from patients who have "opted out".

We would encourage you to think carefully about whether you want your information to be uploaded. For more information please visit the following website: The Big Opt Out – http://www.nhsconfidentiality.org

You DO NOT need to make an appointment with a GP to opt out. Just fill in a form and hand it in, post or fax it to us. We will respect your wishes and will add the appropriate upload–blocking codes to your notes, as well as scanning the letter into your records. Your medical records will then remain under GP– control and not be uploaded whatsoever.

Opting out of the NHS Care Records System will not affect the medical care and treatment that you receive from Dolphins Practice. It will not affect the ability for your GP to refer you to a specialist for further care, should this be necessary, nor does it mean that you will be unable to receive NHS care.

There are no immediate plans to upload your records so you have nothing to lose by opting out now. You can opt in to the NHS Care Records Service at any time in the future if you become satisfied with the security arrangements at a later stage.