Confidentiality
It is important to understand that everyone working in the National Health Service and Local Authorities has a legal and professional duty to ensure that all patient information is safely and securely protected.
Why do we need information?
We ask for information about you so that you can receive proper care and treatment. The information is shared with other parts of health and social care services, and other agencies involved in your care, on a strictly need to know basis.
When other agencies are involved in your care we may need to share information about you so that we can work together for your benefit. Information will only be shared if there is a real need, and where possible, we will ask for your consent.
We are required by law to report certain information about you without your consent:
- where the health and safety of others is at risk
- under special circumstances, for example if a formal court order has been issued
- when approved by the Secretary of State for Health and Social Care
- infectious diseases which may endanger the safety of others, for example, meningitis and measles (but not HIV / Aids)
What information is held?
Apart from specific forms, we only hold information in an electronic format. When you are referred to the service you are given a unique number which is used to identify you and all health records associated with you. Examples of the information we keep are:
- your name, address, date of birth, ethnicity, religion, sexuality, and who referred you
- why and how you were referred to us
- details of the treatments you have received
- medical and family history
- who is working with you
- when you are discharged and why
This information makes up your health record.
Your Health Record
The information will have been recorded by, or on behalf of a health professional involved with your care. The health record helps staff to review the care they provide to you, to make sure it is of the highest standard.
You may find that you will be encouraged to see your records on an on-going basis to help you be involved in planning your care. If this is not the case, the Access to Health Records Act provides a formal route to request access.
Who can gain access?
Applications for access to health records must be made in writing to the Health Records Manager, and can be made by any of the following:
- you, the patient
- a person authorised, in writing, to make the application on your behalf
- any person appointed by the court to manage the affairs of someone who is unable to do this for themselves
There are also rules regarding Specialist Advocacy Support enabling you or your advocate to access your health records under the Care Act, the Mental Capacity Act, and the Mental Health Act. A Specialist Advocate is a person who can support you to ensure you have the right information you need to make the right choices, and to help you speak up and be heard.
Is there a charge to access records?
There is no charge to view your records if you have been a patient in the last forty days.
If you would like a permanent copy of your records, the maximum cost is £10.
Can anyone be refused access?
Yes, all or some of the records may not be made available because:
- you, the patient, have requested or expected that the information would not be made available to another person
- where it is not in your best interests
- where another person, other than you or the health professional, could be identified
How does the application work?
An application to access your health records can be made through a paper form, or online via our Access Request Portal.
You will be asked to complete a form, which will then be checked to ensure that you are allowed access to your health record.
The health professional caring for you is then written to, asking for their permission to release the notes. They will then decide whether access is granted, and will ensure that any terminology is explained.
Access will be granted within 40 days of us receiving your fee for any copies requested. Where an appointment to view is requested, this will normally take place within 21 days.
If access is withheld, you or your representative will be notified.
What if something is wrong?
If you think that your records are inaccurate, ask the record holder to correct them. They must make amendments or attach a statement from you. You have a right to apply to the court for corrections of inaccurate information in your records.