Contractual requirements for IT/electronic patient records
It is a requirement of the NHS GP contract that all GP practices inform their patients of their current status in relation to a number of electronic services:
Electronic transfer of patient record
The system (GP2GP) that electronically transfers patient medical records from one practice to another is already activated at Bethany Medical Centre. Please note at present, where practices have different clinical systems to ours it may not always be possible to transfer records via GP2GP due to limitations on the transfer file size. These records will be manually forwarded and received in the traditional manner.
Electronic appointment booking
This service is available via Patient Access and is hosted by our clinical system provider. Electronic appointment booking will provide a convenient service to arrange appointments directly for patients who may have difficulties contacting the surgery during opening hours.
Electronic booking of repeat prescriptions
This is a useful service for both patients and the practice as requests can be made directly via the online access system.
Electronic transfer of prescriptions (ETPS)
This service enables the GP to forward prescriptions electronically to a patient’s nominated pharmacy. This is a secure and almost instant transfer from when the GP processes the request. It also prevents the need for prescriptions to be collected by patients from the practice as they only need to collect their medications from the pharmacy.
Patients’ access to their GP record
Patients have been able to view their medical record on line since March 2015 and can access their medical records relating to medications, allergies, summary of conditions and adverse reactions.
National data opt-out directive
The national data opt-out was introduced on 25 May 2018, enabling patients to opt out from the use of their data for research or planning purposes, in line with the recommendations of the National Data Guardian in her Review of Data Security, Consent and Opt-Outs.
Patients can view or change their national data opt-out choice at any time by using the online service at www.nhs.uk/your-nhs-data-matters.
Medical records
Your medical record card is a life long history of any consultations, treatment, investigations, etc, that you have had with your doctor since birth. It follows you around wherever you live in the UK and for that reason you should always let us know of any change of circumstances so that we can ensure that the information we hold about you is accurate.
Even though these days most surgeries use computers, the information held on computer is printed out and a copy placed into your medical record card should you move to another doctor.
Your right to privacy
You have a right to keep personal information confidential between you and your doctor. This applies to everyone over the age of 16 and in certain cases those under 16, however, in order look after you properly we normally share some information about you with others involved in your care, unless you ask us not to. This could include doctors, nurses or others involved in the treatment or investigation of your medical problems.
Because we are a teaching practice, involved in the training of medical students and GP registrars, if you see a registrar or medical student during a consultation, they would be allowed access to your medical record.
The practice staff also have access to medical records. They need to perform tasks such as filing of letters, processing repeat prescriptions and provide information about blood tests, etc.
Everyone working for the NHS has a legal duty to keep information about you confidential.
Where else do we send patient records?
We are required by law to notify the Government of certain infectious diseases for public health reasons, eg meningitis, mumps, salmonella and other similar infections (but not AIDS).
Doctors cannot refuse to co-operate with a court of law without risk of serious punishment.
Solicitors ask for sight of medical records, however, in every such instance, the request will be accompanied by your signed consent. A solicitor would usually need sight of your entire medical record since limiting access usually means he is unable to fully represent your case. If you do not want to grant full access, you can ask that the records be supplied between two relevant dates rather than allowing a solicitor unrestricted access.
Insurance companies ask for medical reports on prospective or current clients. Similarly, prospective employers may also wish to investigate your medical history before confirming your appointment to a job. Your signed consent will always accompany such requests. GPs must disclose all relevant medical conditions unless you ask us not to, however, we would then have to inform the requestor that you have instructed us not to make a full disclosure to them. You have the right to see such reports before they are sent, however, if you elect to exercise that right but then do not attend to see the report it will be dispatched to the requestor after 21 days.
Anyone who receives information from us is under a legal duty to keep it confidential.
Can I find out what is in my medical record?
Using Patient Access you can have on-line access to your medical record, test results and medication free of charge 24/7.
Individuals have the right to access their personal data. This is commonly referred to as a subject access request. You can make a subject access request verbally or in writing. We have one month to respond to a request. in most circumstances this will be provided free of charge. Please note: We must make every reasonable effort to ensure that there is no breach of confidentiality when responding to a subject access request.
We have a duty to keep your medical record accurate and up-to-date. Please inform us if you believe there is an inaccuracy in your record.
Please note: Medical records in this practice contain statements of opinion about the likely diagnosis accounting for your problem at a particular time. This diagnosis is entered in order that we can monitor the basis of our actions such as prescribing interventions, etc. Since it is an opinion expressed at the time, it is not unusual for the diagnosis in any episode to differ from it. Often when illnesses are first presented to a doctor, the range in severity of symptoms does not allow more than a tentative diagnosis.
Summary Care Record
The “Summary Care Record” is an electronic summary of a patient’s key clinical information The practice has already activated a summary care record for all patients other than those who have expressed a wish to opt out of this service. This record can only be viewed in emergency or urgent care settings with the consent of the patient unless the patient is unable to give consent (for example if they are unconscious).