ELM Group – Policies
Confidentiality is central to trust between doctors and patients. Without assurances about confidentiality, patients may be reluctant to seek medical attention or to give doctors the information they need in order to provide good care.
Appropriate information sharing is essential to the efficient provision of safe, effective care, both for the individual patient and for the wider community of patients. Your medical records are held on our computer system. The Practice has a stringent security and confidentiality policy which fully complies with the Data Protection Act. Your details are only available to and used by those involved in your care. However this information may be used for research purposes but in such cases will be anonymised and encrypted.
All staff undertake yearly training and assessment in the importance of maintaining patient confidentiality. You have the right to know what information we hold about you.
An example of our commitment to confidentiality is that we cannot divulge information about your appointments to anyone else (this includes telephone consultations). It may be that you share this information with family members but we cannot assume that is the case. Therefore if we contact you about an appointment or for a phone consultation we will not identify ourselves to anyone but you. This can at times appear excessive but is evidence that should there be occasions when you do not want anyone to know you have an appointment at the surgery you can be confident that we will not reveal that information.
Access to Medical Records
The Data Protection Act 1998, which became effective from 1 March 2000, gives every living person (or their authorised representative) the right to apply for access to their health records, irrespective of when they were compiled.
Within the Data Protection Act 1998, a health record is defined as “a record consisting of information about the physical or mental health, or condition, of an identifiable individual, made by, or on behalf of, a health professional, in connection with the care of that individual.”
A health record can be in computerised and/or manual form. It may include such documentation as hand written clinical notes, letters to and from other health professionals, laboratory reports, radiographs and other imaging records, printouts, photographs, videos and tape recordings.
Personal information relating to an individual includes factual information, expressions of opinion, and the intentions of the health professional in relation to the individual concerned.
Application for access to health records
• Any application for access to health records must be made in writing.
• Applications must be signed and dated by the applicant.
• Where an application is made on behalf of an individual, a signed form of consent must accompany the written application.
• The application must clearly identify the patient in question, and the records required, including the following details:
• Full name – including previous names
• Address – including previous address(es)
• NHS number (if available)
• Dates of health records required
The surgery has the right to check with the applicant if they require access to their entire health record, and confirm what material the applicant requires prior to processing the request. This will decrease the cost of copying for the applicant. However, disclosure is optional, as the applicant does not have to provide a reason for applying for access to health records.
Where a request for access to records has previously been complied with, the surgery is not obliged to respond to a subsequent identical or similar request unless a reasonable interval has elapsed since the previous request.
Requests for access to records made by a patient representative
A patient can authorise a representative to access their health records on their behalf. This must be done in writing, with confirmation of the representative’s identity and relationship to the patient.
Representatives able to provide evidence that they are acting under power of attorney will be granted access to the health records of the patient.
Where a patient who is physically or mentally disabled and unable to provide written consent for a representative to seek access on their behalf, the surgery will give the patient as much assistance as possible, in order to ascertain whether consent has been granted by other means.
Parents, or those with parental responsibility, will generally have the right to apply for access to a child’s health record.
Fees to access and copy health records
Under the Data Protection Act 1998 (Fees and Miscellaneous Provisions) Regulations 2001, a patient can be charged to view their health records, or to be provided with a copy of them.
Maximum charges will include postage and packaging costs, and are intended to cover the reasonable administrative costs of disclosure. Charges for access requests should not be made for financial gain.
To provide copies of patient health records, the maximum costs are as follows:
• Health records held on computer – a maximum charge of £10.00
• Health records held both on computer and manually – a maximum charge of £50.00
• Health records held manually a maximum charge of £50.00
If patients wish to view their health records (where no copy is required), access is free if the records have been added to within the last 40 days.
Otherwise, a maximum charge of £10.00 is recommended.
If a patient wishes to view their records and subsequently makes a request for copies, the patient will be charged as per one access request, to a maximum of £50.00.
Access to computerised Medical Records – £10.00
Copies of paper Medical Records – £0.50 per A4 sheet up to a maximum of £50.00