Records and Confidentiality
Contents
Medical Records
Overview
Consistent and continuous patient
care is reliant upon clear, accurate, and current GP
patient records. These should include all relevant clinical
findings, the decisions made, the information given to patients,
and any drugs or other treatment prescribed.
Records are vital not only to
provide a historical narrative to the GP of their individual care
of a patient, but also to keep colleagues well informed when
sharing the care of patients.
Electronic Patient Records
With the advent of the
NHS Care Records Service the NHS is
moving towards a system based wholly upon electronic patient
medical records. The service will give authorised NHS staff 24 hour
access to up-to-date, accurate patient information, hopefully
making diagnosis and treatment safer and faster. At whatever point
the patient enters the NHS system authorised staff will have access
to the core medical history of that individual - such as what
medication they are on and any allergies they may have.
Electronic records
will reduce form-filling for patients and staff alike and
basic information will not have to be repeatedly recorded every
time a patient enters the NHS system. Test results, clinical images
such as scans and x-rays, and letters regarding the
patient, will also be electronically attached to the record
saving time for doctors and their patients.
Within a few years, every patient will have a Summary Care
Record containing key diagnoses and problems, current and recent
prescriptions, and important information such as allergies and drug
reactions. Discharge and out-patient care summaries will be there
as will highlights from out of hours or A&E care. The Summary
Care Record will be available to a health professional when a
patient consults them anywhere in England. It will become
the natural starting point when, for example, a registered
patient consults another GP in the practice for the first
time.
GPs and other health records will continue to keep complete
clinical records of a patient’s consultation. In total these
records will constitute, within a locality, a patient’s Detailed
Care Record. If a GP wants to know why a drug was changed, for
example, and it’s not clear from the discharge summary, the GP can
look into the local hospital record.
Throughout England, primary care staff are being issued with
identifying smart cards, and to see a patient’s record they
will need to have a “legitimate relationship”. In the case of GPs
that means the patient is registered with the GP, is a temporary
resident, or is being seen for urgent care.
The initial Summary Care Record will not include
mental health data or information on some infections. When these
patients are seen in the practice, they will be asked which of
these sensitive aspects they want to include in their Summary Care
Record. Patients will be also able to say if they do not want a
Summary Care Record at all or to wall off parts of it from
being seen (the so-called “sealed envelope”). They will be
also able to limit the sharing of their Detailed Care Record
or restrict parts of their record from being seen. The NHS has
produced a
patient guarantee which describes how
the NHS will protect confidential health information held on
computers.
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Standards for Medical Records
The NHS has recently produced
standards for the holding,
maintaining and accessing of patient health records. Key principles
include:
- Patients have a right to know when
information is recorded about them, how the information will be
recorded and how their information may be used in the future.
- Patients have a right to access
their own records, and to limit the healthcare professional’s
access to their information. Exceptions may apply if
restricting or withholding information would cause serious harm to
the patient or others.
- Information must be presented to
patients in a way they can understand. Unnecessary abbreviations or
jargon, meaningless phrases, irrelevant/offensive speculation or
personal opinions regarding the patient should not be
included.
- All encounters and interventions
made relating to a patient must be recorded. This includes when a
patient has not been involved directly.
- Patient records should be clear,
accurate, legible, written at the time of the
consultation, and attributed to a named person with an
identified role.
- Any justifiable alterations to
documentation should be clearly attributed to a named person with
an identified role, with the original documentation and alterations
clearly legible and auditable.
- Records should contain details of
any assessments undertaken and clear evidence of the arrangements
that have been planned for continuing care, including the
information given to patients about their care and treatment.
These standards are supplemented by
an NHS Code of Practice establishing the requirements for
records management in relation to the creation, use, storage,
management and disposal of patient medical records.
NHS Code of Practice: Records
Management (Department of Health)
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Access to Medical Records and Freedom of Information
Access to Medical Records
Doctors have always been entitled
to informally show patients their records or, bearing in mind
duties of confidentiality, discuss relevant health issues with
carers. However, there are now more formal rules and application
procedures to support patient rights in this area. The Data
Protection Act 1998 established the right of patients to access
health records which are about their care and from which they can
be identified.
Access must be given equally to
all records regardless of when they were made, and patients are
entitled to a copy of their records, for example a photocopy of
paper records or print out of computerised records. A fee can be
charged for access (see guidance below) which varies depending
on the type of record and whether the patient requires copies of
the records or just to see them.
Access to records is not totally
absolute and information must not be disclosed if it is likely to
cause serious physical or mental harm to the patient or another
person; or relates to a third party who has not given consent for
disclosure.
Competent patients may apply for
access to their own records, or may authorise a third party, such
as their lawyer, to do so on their behalf. Parents may have access
to their child’s record if this is in the best interests of
the child and not contrary to a competent child’s wishes.
People appointed by a court to manage the affairs of mentally
incapacitated adults may have access to information necessary to
fulfill their function.
Freedom of Information
The Freedom of Information Act
obliges a GP practice to respond to requests about recorded
information that it holds; and creates a right of access
to that information. Practices must:
- Have a publication scheme in
place.
- Respond to individuals’ requests
for information.
A publication scheme is a list or
index of:
- The types of information that a
practice holds.
- A description of how it can be
obtained.
- An explanation of any charges that
might apply.
- An explanation of
the information that the GP holds but cannot make
available.
Under the Act, any individual
anywhere in the world, is able to make a request to a practice for
information regardless of whether he/she is the subject of the
information or affected by its use. An applicant is entitled
to be informed in writing whether the practice holds the
specified information and to have the information communicated to
them within 20 working days. Where a fee is required (see link
below), the deadline will be extended until the fee is paid.
Personal information relating to
individual patients, the handling and disclosure of which is
regulated by the Data Protection Act 1998, is exempt from the
Freedom of Information Act. Information that would harm the
commercial interests of the practice, or that is against the public
interest is also exempt.
Understanding Your Medical Records
The RCGP has developed a webpage
listing some of the
main
abbreviations and denotations that may be used in
patient medical records.
Patients may also find useful the
Acronyms Finder –
hosted on the RCGP website but maintained by
Medilexicon –
which allows the searching of medical abbreviations using
the abbreviation or the definition eg
RCGP or
Royal
College of General Practitioners.
Confidentiality and Consent
Confidentiality
Patients often entrust health
professionals with sensitive information relating to their health
and other matters. They do so in confidence and have the legitimate
expectation that staff will respect their privacy and act
appropriately.
Patient information is generally
held under legal and ethical obligations of confidentiality, and
should not be used or disclosed in a form that might identify a
patient without his or her explicit consent. There are a number of
important exceptions to this rule (see NHS link below), but it
applies in most circumstances. Anonymised health information,
where names have been removed, is not confidential and
may be used with relatively few constraints.
The NHS has produced a code of
required confidentiality good practice for those who work within
NHS organisations.
Confidentiality
(NHS Code of Practice)
Consent
Before any doctor, nurse or
therapist examines or treats a patient, they must seek consent or
permission. This could simply mean following their suggestions,
such as the GP asking to have a look down a
patients throat and them showing consent by opening their
mouth. Sometimes patients will be asked to sign a form,
depending on the seriousness of what is being proposed
and whether it carries risks as well as benefits.
It does not matter so much how
consent is shown, what is important is that consent is genuine or
valid. This means a patient must be given enough
information to enable them to make a decision, and they must be
acting under their own free will and not under the strong influence
of another person.
The Department of Health
website includes
consent guidance for adults,
children and young people, people with learning disabilities,
parents, relatives and carers, as well as a general reference guide
to consent for examination or treatment.
Create Your Own Health Record
The NHS online
tool
HealthSpace is
a secure place on the Internet where patients can store personal
health information for their own use. Users are able to
add information such as their blood group, weight, allergies
and medication, as well as contact details, dates and times of
appointments, and favourite health related web links. Users
can also register to receive e-mail reminders to attend
appointments.
When the NHS Care Records Service
is fully implemented patients will be able to use HealthSpace to
access their real NHS patient records and enter their own comments,
such as their organ donation preferences, or data – home blood
pressure readings for example.