Confidentiality and Access to Records
Data Protection Act – Patient Information
We need to hold personal information about you on our computer system and in paper records to help us to look after your health needs, and your doctor is responsible for their accuracy and safe-keeping. Please help to keep your record up to date by informing us of any changes to your circumstances.
Doctors and staff in the practice have access to your medical records to enable them to do their jobs. From time to time information may be shared with others involved in your care if it is necessary. Anyone with access to your record is properly trained in confidentiality issues and is governed by both a legal and contractual duty to keep your details private.
All information about you is held securely and appropriate safeguards are in place to prevent accidental loss.
In some circumstances we may be required by law to release your details to statutory or other official bodies, for example if a court order is presented, or in the case of public health issues. In other circumstances you may be required to give written consent before information is released – such as for medical reports for insurance, solicitors etc.
To ensure your privacy, we will not disclose information over the telephone or fax unless we are sure that we are talking to you. Information will not be disclosed to family, friends, or spouses unless we have prior written consent, and we do not leave messages with others.
You have a right to see your records if you wish. Please ask at reception if you would like further details and our patient information leaflet. An appointment will be required. In some circumstances a fee may be payable.
If you would like a chaperone present at any time during a consultation when you are being examined please let your clinician know. We will be happy to organise for another member of staff to be present at that examination.
Our staff are here to help you and are entitled to be treated fairly and with respect whilst working at the surgery.
Violent or Abusive Patients
Violent, threatening or abusive behaviour will not be tolerated and you may be removed from the practice list.
Sharing of your record
For information on sharing your record with other Health Professionals can be seen in the Record Sharing - Patient Leaflet
The purpose of this protocol is to set out the Practice’s approach to consent and the way in which the principles of consent will be put into practise.
Where possible, a clinician must be satisfied that a patient understands and consents to a proposed treatment, immunisations or investigation.
Implied consent will be assumed for many routine physical contacts with patients. Where implied consent is to be assumed by the clinician, in all cases, the following will apply:
An explanation will be given to the patient what he/she is about to do and why.
The explanation will be sufficient for the patient to understand the procedure.
In all cases where the patient is under 18 years of age a verbal confirmation of consent will be obtained and briefly entered into the medical record.
Where there is a significant risk to the patient an ‘Expressed Consent’ will be obtained in all cases (see below).
Expressed consent (written or verbal) will be obtained for any procedure which carries a risk that the patient is likely to consider as being substantial. A note will be made in the medical record detailing the discussion about the consent and the risks. A Consent form may be used for the patient to express consent (see below).
Consent (Implied or Expressed) will be obtained prior to the procedure.
The clinician will ensure that the patient is competent to provide a consent (16 years or over) or has ‘Gillick Competence’ if under 16 years (has 'sufficient understanding and maturity to enable them to understand fully what is proposed'). For children under 16 someone with parental responsibility should give consent on the child’s behalf by signing accordingly on the Consent Form.