Background
For a number of years, work has been going on to improve the way that medical records are made available to treating clinicians. As a result of this work we are now able to share clinical information between certain health professionals.
This means that, with your consent, we are able to share your medical records with those in the NHS who are involved in your care. NHS staff can only access shared information if they are involved in your care and being an electronic service an audit log is maintained showing when and who accessed medical records.
This helps clinicians to make decisions based upon a wider knowledge of you and also helps to reduce the number of times that you or your family members are asked the same question. In short it assists clinicians to provide more ‘joined up care’.
We already share records of children for child protection reasons and patients who are under the care of the district nursing team.
If I agree, who can see my record?
Clinicians treating you, who have access to the same system, can view and in some cases update your medical records. Locally this includes the walk in centre, many departments at local hospitals (including A&E) and community services, such as the district nursing team. It is anticipated that over time more health services will be able to us this system to access records, if appropriate.
Clinicians outside of the surgery who wish to access your medical records will ask for your permission to do so and will need to have been issued with a NHS Smartcard – this is a ‘chip and pin’ card, similar to a bank card.
Can I choose who sees my record?
Yes you can – there are two levels of consent. The first is to agree to sharing your medical records out of the practice. This is your agreement that records maintained by your GP can be seen, subject to your authority at the time, by clinicians working outside of the surgery. The second is agreeing to share your records in. This means that your GP can see the records made by other health professionals who have access to EDSM.
However, as the treating clinician needs to ask your permission to see the records at the beginning of each period of care you are in control of who can see your medical information.
What can I do if I don’t want to allow access to my records?
As we feel this access will enhance patient care we will automatically ‘opt you in’ to both parts of the scheme. If you prefer not to be then please mention it to a member of the reception team. You are free to change your mind at any time.
I can see the benefits of the other people treating me seeing my notes, but what if there is a matter that I want to stay just between me and my doctor?
You can ask for any consultation to be marked as ‘private’. This means that viewing is restricted to the surgery, but allows the rest of the record to be viewed by whoever else is treating you. It is your responsibility to ask for a consultation to be marked as ‘private’.
How is this different from previous arrangements?
In the past other NHS Services are able to see your current medications and the drugs that you are allergic or sensitive to via a Summary Care Record (SCR). This new system will allow your full record to be seen.
Can I change my mind?
Yes, you can always change your mind and amend who you consent to see your records. For instance, you can decline to share your records out from the surgery, but if you built up a relationship with a physiotherapist who was treating you and they asked you if they could look at an x-ray report, you could give your consent at that point for them to view your records.
You will be referred back to us to change your preference, so the physiotherapist treating you should, with your permission, be able to see your records at the time of your next appointment.
If I decline, what happens in an emergency?
In the event of a medical emergency, for instance, if you were taken unconscious to A&E, and the clinician treating you feels it is important to be able to see your medical records, he is able to override any consents set. However, the doctor has to give a written reason for doing so. Where this happens an audit is undertaken by the local Caldicott Guardian (the person with the overall responsibility for Data Protection compliance).
Can anyone else see my medical records?
Not unless you give your written consent for this to happen. On a daily basis we get requests from insurance companies to either have copies of medical records or excerpts from patient’s medical records.
This requires your signed consent as it has not been requested to treat/care for you.
Occasionally we are asked for information from your medical records for legal reasons, again, this has to be done with your written consent or, in very exceptional circumstances, by court order.
Any questions?
If you have any questions, please speak to reception. If necessary the receptionist will arrange for another member of the team to give you a call.