Your Medical Record

How we collect information about you and how that information may be used

Overview

All the health care professionals that look after you maintain records about your health and any treatment or care that you have previously received. This includes hospitals, GP surgeries, walk-in clinics etc.

NHS health records may be electronic, paper-base or a mixture of both and we will ensure that all your information is kept confidential and secure.

Information which this GP Practice holds about you may include:

  • Details about you, such as your address, carer, legal representative, emergency contacts
  • Any contact the surgery has had with you in the past, such as appointments, clinic visits, emergency appointments, etc.
  • Notes and reports about your health
  • Details about your treatment and care
  • Results of investigations such as laboratory tests, x-rays etc
  • Relevant information from other health professionals, relatives or those who care for you

Your records are used to ensure you receive the best possible care. Information held about you may also be used to help protect the health of the public and for a clinical audit to monitor the quality of the service provided.

Some of this information will be held centrally and used for statistical purposes. Where we do this, we take strict measures to make sure that individual patients cannot be identified. Occasionally your information may also be requested for research purposes. The practice will always ask for your consent before agreeing to do this.

Identifying patients’ health risks

Risk identification tools are increasingly being used in the NHS to help understand a patient’s risk of suffering from a particular condition in the future. As once we know this we can offer preventative intervention.

Information about you is collected from a number of sources including NHS Trusts and from this GP Practice. A risk score is then arrived at through an analysis of your de-identified information using software managed by NHS England. Risk stratification enables your GP to focus on preventing ill health and offer you additional services to help you not to become ill in the future. Please note that you have the right to opt-out of your data being used in this way.

Medicines Management

The Practice may carry out reviews of the medications prescribed to its patients to ensure that all patients are receiving the most appropriate, up to date and cost-effective treatments.

How Do We Maintain The Confidentiality Of Your Records?

We are committed to protecting your privacy and will only use information collected lawfully in accordance with:

  • Data Protection Act 1998
  • Human Rights Act 1998
  • Common Law Duty of Confidentiality
  • Health and Social Care Act 2012
  • NHS Codes of Confidentiality, Information Security and Records Management
  • Information: To Share or Not to Share Review

Every member of staff who works for an NHS organisation has a legal obligation to keep information about you confidential.

We will only ever use or pass on information about you if others, involved in your care, have a genuine need for it. We will not disclose your information to any third party without your permission unless there are exceptional circumstances (i.e. life or death situations), where the law requires information to be passed on and/or in accordance with the new information sharing principle following Dame Fiona Caldicott’s information sharing review where “The duty to share information can be as important as the duty to protect patient confidentiality.” This means that health and social care professionals should have the confidence to share information in the best interests of their patients within the framework set out by the Caldicott principles. They should be supported by the policies of their employers, regulators and professional bodies.

Who Are Our Partner Organisations?

We may also have to share your information, subject to strict agreements on how it will be used, with the following organisations:

  • NHS Trusts/Foundation Trusts
  • GPs
  • NHS Commissioning Support Units
  • Independent contractors such as dentists, opticians, pharmacists
  • Private sector providers
  • Voluntary sector providers
  • Ambulance Trusts
  • Clinical Commissioning Groups
  • Social Care Services
  • Health and Social Care Information Centre (HSCIC)
  • Local Authorities
  • Education Services
  • Fire and Rescue Services
  • Police & Judicial Services
  • Other ‘data processors’ which you will be informed of

You will be informed who your data will be shared with and in some cases asked for explicit consent for this to happen.

We may also use external companies to process personal information, such as for archiving purposes. These companies are bound by contractual agreements to ensure information is kept confidential and secure.

Access To Personal Information

You have a right, under the Data Protection Act 1998, to request access to view or to obtain copies of what information the surgery holds about you and to have it amended should it be inaccurate. In order to request this, you need to do the following:

  • Your request must be made in writing to the GP – for information from the hospital you should write direct to them
  • There may be a charge to receive a printed copy of the information
  • We are required to respond to you within 40 days
  • You will need to give adequate information (for example full name, address, date of birth, NHS number and details of your request) so that your identity can be verified and your records located

Objections/Complaints

Should you have any concerns about how your information is managed, please contact our Deputy Practice Manager at either Ireland Wood or New Croft Surgery. If you are still unhappy, following a review by the Practice you can complain to the Information Commissioners Office (ICO) via their website, email: casework@ico.org.uk, Tel: 0303 123 1113 (local rate) or 01625 545 745.

Cookies

We do not use cookies on this website.

Change of Details

It is important that you tell the person treating you if any of your details, such as your name or address, have changed or if any of your details such as date of birth is incorrect so that we can amend this. You have a responsibility to inform us of any changes so our records are accurate and up to date for you.

Notification

The Data Protection Act 1998 requires organisations to register the purposes for which they process personal and sensitive information. This information is publicly available on the Information Commissioner’s website. The practice is registered with the Information Commissioners Office (ICO).

Who is the Data Controller?

The Data Controller, responsible for keeping your information secure and confidential is Dr Brown (on behalf of Ireland Wood and Horsforth Medical Practice)

Leeds Care Record

The Leeds Care Record provides health and social care professionals directly involved in your care access to the most up to date information about you.

Data shared with who and why?

Leeds Teaching Hospital Trust/Primary Care such as your GP/Leeds Mental Health/Leeds Social Care. It is designed to be a local one stop shop shared record for direct care to enable health professionals to provide better care by seeing all your information together in one place.

What is shared?

Problems, Medication, Allergies, Appointments, Test Results, Communications, Discharges, Demographics.

How is the data shared?

Held on a secure computer system and records remain confidential. All existing data protection laws apply. Only accessed by people directly involved in your care. This is role based access by Leeds Teaching Hospital Trust/Primary Care/Leeds Mental Health/Leeds Social Care.

How is consent given?

GP Practices Opt in to Leeds Care Record. Patients can opt out via Leeds Teaching Hospital Trust (by phone on 0113 206 4102, by email “leeds.carerecord@nhs.net”, or by letter to “Access to Health Records, Leeds Teaching Hospitals NHS Trust, St James University Hospital, Lincoln Wing/Chancellor Wing Link Corridor, Beckett Street, Leeds, LS9 7TF”).

How do I get more information?

Go to Leeds Care Record Website.

National Diabetes Audit

This GP practice is taking part in the National Diabetes Audit which is an important national project about diabetes care and treatment in the NHS

This GP practice is taking part in an important national project about diabetes care and treatment in the NHS. The project is called the National Diabetes Audit (NDA).

To take part, your GP practice will share information about your diabetes care and treatment with the NDA. The type of information, and how it is shared, is controlled by law and enforced by strict rules of confidentiality and security.

For further information about how your information is used please see the NDA patient information leaflet. Taking part in the NDA shows that this GP practice is committed to improving care for people with diabetes.

If you do not want your information to be used, please inform the receptionist, your GP or nurse. This will not affect your care.

Online Patient Access

If you are registered for NHS Online you can book an appointment, check test results, and see the diagnosis and treatment details in your GP medical record

Accessing GP services and medical records online

You can now:
View a detailed version of your medical records, including:
*Demographic details: Your name, address, date of birth.
*Appointment details: The GP you saw; appointment date; reason for the visit; history; examination and outcome.
*Problems/diagnoses: Details of your medical conditions.
*Allergies and adverse reactions to medication: For example, you may have previously reacted badly to penicillin.
*Medication: The dose, quantity, and when medication was last issued.
*Immunisations: Influenza or tetanus, for example.
*Values: Blood pressure readings, for example.
*Procedure details: Medical or surgical information, and codes in consultation (signs, symptoms).
*Links: Links to information about your treatment or diagnosis.
*Letters and attachments: A note that your GP has communicated with another clinician, for example, a hospital consultant. The letter itself may not be included.

ONLINE ACCESS FORM

What you can’t see and why

A GP may believe it is not in the best interests of a patient to see all the information in their medical record. GPs can withhold “free text” notes and administrative information.
Book an appointment to see your GP: Most surgeries now let you book, view, amend and cancel appointments online.
Request a repeat prescription: Most GPs now allow patients to request a repeat prescription online.
Get test results: Many test results are now available online. GPs may still request a face-to-face or telephone appointment to discuss some results.

How do I access online services with my GP surgery?

Ask at reception about registering to use online services. They will explain the options, including logging in securely via the NHS website or using a smartphone app, such as NHS App.
You will be given an information leaflet and asked to complete a registration form and questionnaire. Once appropriate checks are completed, you will be registered for online access and given a username and unique password.

Are my records secure?

The clinical software systems used to store patient medical records are designed to be secure. It’s important to choose a strong password and keep it secret.
Keep your device (smartphone, iPad or desktop) secure too and log out after viewing your record.
Before sharing your record with anyone, consider whether it’s in your best interests and how that information might be used.

Who can see my medical records?

Your health records are confidential and can only be seen by a healthcare professional on a need-to-know basis.
You can allow other people to see your health records, for example, a pharmacist.
What can I do if my GP refuses access to my medical record?
A refusal to grant medical records access can be challenged through an official complaint to the NHS Trust or social services department concerned or via the Information Commissioner’s Office (01625 54 57 45).

Understanding your records

Your records are written to help medical people look after you and so sometimes you may not understand everything you see. If you find anything difficult to understand, as well as talking to your doctor or nurse, you can go to www.patient.info or the NHS Choices website.
NHS Choices has more information about accessing medical records.

How is consent given?

You apply for access via the reception desk. The Dr has the option to accept or deny patients request to access record. We only deny access in exceptional circumstances.

Proxy Access

You can grant access to your medical record to another individual/s should you wish to do so. Proxy access only allows access to medications and booking appointments. Download the application form to apply for proxy access – ONLINE PROXY ACCESS FORM

Enhanced Data Sharing Model

Sharing enables a clinician to get a full picture of all elements that affect your treatment.

Data shared with who and why?

Many GP practices in Leeds, the out of hours on-call Doctor service and many other organisations use the Leeds Care Records service to share information about your care

This means that if we refer you to a service that is already using Leeds Care Record, the person you go and see will have access to your GP record and visa versa. This allows for safer care and means you have to repeat your story less often.

What is shared?

All data unless specific items are marked as private.

How is the data shared?

Access is restricted to NHS Smartcard holders in Hospitals, Out of Hours Services, Community Health and GPs.

How is consent given?

Initial implied consent with explicit consent for a share in and out at each organisation.

How do I get more information?

For further detailed information on how the record sharing works in our system is available from the waiting room

We are in the process of asking your sharing preferences regarding your full detailed electronic record. We are telling you about this, as you have a choice to make. You can choose to share or not to share your full electronic record with other NHS care services where you are treated and whether we can view records held by those other services.

If you choose to make your record shareable, your clinical details will only viewable by clinical teams who are treating you.

Each clinical team which cares for you now or in the future will ask your permission to view your shared record. You can also ask for part of your record to be made private – not shareable. All record accesses are recorded and auditable. If you choose not to make your records shareable, we will respect your wishes and will do our best to make your care safe and efficient. However, denying the clinical teams caring for you the ability to access important clinical details could compromise your care.

You Have Two Choices:

    • Sharing Out – This controls whether your full electronic patient record can be shared with other NHS care services where you are treated.

Let us know if your records should be Shareable or Not Shareable.

    • Sharing In – This controls whether you agree for this service to view the information you’ve agreed to share at other NHS care services.

Let us know if we can view your shared record from elsewhere or if you do not want it to be viewable to us.

In the event of an emergency: In certain circumstances, such as if you are unconscious or there is a court order, healthcare staff may look at your record without asking you. If they have to do this, a note will be made on your record. If we share information without your permission, we will make sure that we keep to the Data Protection Act 1998, the NHS confidentiality code of practice and other national guidelines on best practice.

Summary Care Record

The Summary Care Record is a national electronic record which contains information about your current medication and any allergies or adverse reactions that you may have.

Having this information stored in one place makes it easier for healthcare staff to treat you in an emergency.

Who is my data shared with and why?

The National Care Record Service (NCRS) for sharing important summary clinical data nationwide for emergency direct care purposes. For example, if you were admitted to hospital in a different part of the country this record would enable the doctors to see vital information about your care.

What is shared?

Medication, Allergies, Drug reactions, optionally specific Read coded entries (called rich SCR).

How is the data shared?

Access is restricted to NHS Smartcard holders in Hospitals, Out of Hours Services and GPs.

How is consent given?

Implied consent with patient opt out via Read Code and requirement to explicitly opt in for Rich SCR.

How do I get more information?

You can also visit the NHS Care Records website or download the NHS Care Record Guarantee.

Research

Ireland Wood and New Croft Surgery are actively contributing to medical research which we believe plays an important role in improving the medicine we practice.

Overview

As well being committed to improving the care our own patients receive, we also believe in helping the progress of medicine in general. We have joined the National Institute for Health Research as a ‘research ready practice’ and have been approved by the Royal College of General Practitioners.

By being part of this network we hope to help develop medical research within primary care. This can mean supporting research studies and clinical trials, collecting data and working in partnership with other practices and NHS organisations.

We have participated in several studies already such as the management of pain from cancer, hand osteoarthritis and helicobacter eradication. Please ask your own GP if you are interested in taking part in research studies.

What does this mean for patients?

It simply means that occasionally we could ask you if you would be interested in participating in some research, in the same way, you might be asked if you go to a local hospital. However, you do not have to take part if you do not want to.

Research Ready

As well being committed to improving the care our own patients receive, we also believe in helping the progress of medicine in general. We have joined the National Institute for Health Research as a ‘research ready practice’ and have been approved by the Royal College of General Practitioners.