Privacy and Confidentiality of your medical records
Your medical record is a life-long history of your consultations, illnesses, investigations, prescriptions and other treatments. The doctor-patient relationship sits at the heart of good general practice and is based on mutual trust and confidence. The story of that relationship over the years is your medical record.
Your GP is responsible for the accuracy and safekeeping of your medical records. You can help us to keep it accurate by informing us of any change in your name, address, marital status and by ensuring that we have full details of your important medical history.
If you move to another area or change GP, we will send your medical records to the local Health Authority to be passed on to your new practice. However, we will keep a copy of all entries in your records whilst you are registered with us.
Your right to privacy
You have a right to keep your personal health information confidential between you and your doctor. This applies to everyone over the age of 16 years and in certain cases to those under 16. The law does impose a few exceptions to this rule, but apart from those (listed in detail below) you have a right to know who has access to your medical record.
Who else sees my records?
There is a balance between your privacy and safety, and we will normally share some information about you with others involved in your health care, unless you ask us not to. This could include doctors, nurses, therapists and technicians involved in the treatment or investigation of your medical problems.
This practice is involved in the teaching of medical students and the training in General Practice of young doctors. If you see a medical student or GP trainee during a consultation, they may be given supervised access to your medical record.
Our practice nurses, district nurses, midwives and health visitors all have access to the medical records of their patients. It is our policy to try to have a single medical and nursing record for each patient. We firmly believe that this offers the best opportunity for delivering the highest quality of care from a modern primary care team.
Our practice staff have limited access to medical records. They need to notify the health authority of registration and claim details and perform various filing tasks on the medical records.
All our doctors, nurses and staff have a legal, ethical and contractual duty to protect your privacy and confidentiality.
Where else do we send Patient information?
We are required by law to notify the Government of certain infectious diseases (e.g. meningitis, measles but not AIDS) for public health reasons.
The law courts can also insist that GPs disclose medical records to them. Doctors cannot refuse to cooperate with the court without risking serious punishment. We are often asked for medical reports from solicitors. These will always be accompanied by the patient’s signed consent for us to disclose information. We will not normally release details about other people that are contained in your records (e.g. wife, children, parents etc) unless we also have their consent.
Limited information is shared with health authorities to help them organise national programmes for public health, such as childhood immunisations, cervical smear tests and breast screening.
GPs must keep the health authorities up to date with all registration changes, additions and deletions. We also notify the health authority of certain procedures that we carry out on patients, such as contraceptive and maternity services, minor operations, night visits, and booster vaccinations.
Social Services and the Benefits Agency and others may require medical reports on you from time to time. These will often be accompanied by your signed consent to disclose information. Failure to cooperate with these agencies can lead to patients’ loss of benefit or other support. However, if we have not received your signed consent we will not normally disclose information about you.
Life Assurance companies frequently ask for medical reports on prospective clients from the GP. These are always accompanied by your signed consent form. GPs must disclose all relevant medical conditions unless you ask us not to do so. In that case we would have to inform the insurance company that you have instructed us not to make a full disclosure to them. You have the right, should you request it, to see reports to insurance companies or employers before they are sent.
How can I find out what is in my medical records?
We are required by law to allow you access to your medical records. If you wish to see your records please contact a member of practice staff for further advice. All requests to view medical records should be made in writing to the surgery. We are allowed by law to charge a small fee to cover our administration and costs.
We have a duty to keep your medical records accurate and up to date. Please feel free to correct any errors of fact that may have crept into your medical record over the years.
What we will not do
To protect your privacy and confidentiality we will not normally disclose any medical information over the telephone or fax unless we are sure that we are talking to you. This means that we will not disclose information to your family, friends, and colleagues about any medical matters at all, unless we know that we have your consent to do so.
This also means that we will not normally disclose test results over the phone and may wish to call you back to ensure that we are talking to the right person.
Our staff will not disclose any details at all about patients over the telephone. Please do not ask them to – they are instructed to protect your privacy.
Finally if you have any further queries, comments or complaints about privacy and your medical records, then please contact a member of practice staff or talk to your own GP.