Your Medical Record

Your medical record is your lifelong medical history. It holds details of your consultations, illnesses, tests, prescriptions and other treatments that have been written by everyone involved in your treatment and care e.g. district nurses, social services etc. By consulting this information we are able to provide you with the best, most appropriate health care.

Some of this information is held electronically on computer and some on paper. It is kept as a history of your treatment to ensure you receive the best possible care now and in the future.

Your GP is responsible for the accuracy and safekeeping of your medical records.

Keeping your Information Secure and Confidential

Our members of staff are trained in information security and confidentiality. There are strict codes of conduct in place to ensure that all your information, be it on paper or computer, is safe. It is written into all our staff contracts that it is a serious disciplinary offence to breach confidentiality and may lead to a staff member’s dismissal. If you disclose sensitive information that you strongly feel should not be shared with the practice team please discuss this in your consultation to enable the doctor or nurse to take appropriate action in their record keeping.

This is a teaching and training practice and undergraduate students and GP registrars may be involved in your consultation. Your permission to participate in consultations with these doctors will always be sought.

Using your information

This practice needs information about you so that you can receive the best possible care and treatment. It may be needed if we see you again, or shared with other organisations involved in your care.

We may need to use some of this information, for example:

• To help protect the health of the public generally – we are required by law to notify the government of certain diseases, e.g. meningitis or measles, but not AIDS.
• Planning for the future – this includes sending information to Health Authorities and the Department of Health e.g. breast screening etc.
• Training staff
• Auditing accounts
• To carry out other health research by use of statistics (your personal details will be non-identifiable) e.g. waiting list information.
• Investigating complaints or legal claims – your information will need to be accompanied by your written consent before being passed on to solicitors etc.*
• Sometimes the law requires us to pass on information e.g. to notify a birth or death.
  
  *When you sign to give permission for your representative (solicitor etc) to access your records, please be aware that this gives consent for that person to access the WHOLE of your medical record, when you may only intend that they should have access to the part of it that is relevant to your needs. Your records may contain information that you would rather withhold from such representation. You may wish to stipulate to which part/s of the record they may have access.

Information Sharing

You may be receiving care from other people as well as your GP (e.g. NHS Hospital Trust, Social Services, private hospitals etc). So that we can all work together for your benefit we may need to share some information about you.

We only ever pass on information about you if it is in your interest with regard to your health. Whenever we can we shall remove details which identify you. The law strictly controls the sharing of some types of very sensitive personal information. Your personal details will not be used for research purposes unless you have been informed beforehand and given your consent for us to do so.

In order to assure the quality of the care and training we provide our clinical records are sometimes inspected by outside visitors. The visitors must make undertakings to keep your records confidential before we will allow them to see them. You can refuse to participate in these inspections by informing the reception staff appropriately.

Access to your Health Records

We have an obligation by law to allow you access to your records. We are allowed to charge a fee to cover our administration and photocopying costs. Please see the charging structure. All requests to access medical records must be in writing for security purposes. We have a duty to keep your medical records accurate and up to date. If any errors of fact have appeared in your record, please draw our attention to them so that they can be corrected

Complaints, Comments and Suggestions

If you should find it necessary to make a complaint please ask to speak to the Reception Manager or the Practice Manager in the first instance. If neither of these people are not available please put the details of your complaint on a special form available at reception. Your complaint will be acknowledged within 3 working days where possible and you may be contacted for further details.

We endeavour to make our service as user-friendly as possible, and welcome any comments or suggestions you may have to help us to do this. Please put your suggestions briefly in writing, and place in the box where the repeat prescription requests are collected. Please remember to put your name and either a contact telephone number or address so that your communication can be acknowledged.

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The Health Service Ombudsman

The Health Service Ombudsman has published a booklet that describes the ‘six principles for remedy’ in relation to complaints handling and involves:

1. Getting it right
2. Being customer focused
3. Being open and accountable
4. Acting fairly and proportionately
5. Putting things right
6. Seeking continuous improvements

If you remain unhappy after everything has been done to try to resolve your concern or complaint you have the right to approach the Ombudsman.
Tel: 0345 015 4033
Email: phso.enquiries@ombudsman.org.uk
Write: Millbank Tower, Millbank, London SW1P 4QP.

Rights and Responsibilities

1. Patients have a right to be greeted courteously.
2. Patients have a right to absolute confidentiality.
3. Any delay in meeting appointment times will be due to medical necessity – where there is a delay in excess of 30 minutes, patients have a right to be informed and to make an alternative appointment.
4. Patients have a right to information about their own health and choices, particularly:
   the illness and its treatment
   alternative forms of treatment
   likely outcome of the illness
5. Access to health records subject to any limitation in the law and to know that those working for the practice are under a legal duty to keep their contents confidential.
6. The practice will offer advice and seek to inform patients of:
   Steps they can take to promote good health and to avoid illness, e.g. smoking, exercise, diet, immunisation,
   Advice on self-help which can be undertaken without reference to a nurse, health visitor or doctor in the case of minor ailments.
7. The practice will inform patients of services available by means of its brochure, notice-boards, leaflets and website.
8. Patients requiring urgent medical attention will be given priority and will be seen as soon as possible, even when this means a delay to booked appointments.
9. Patients may choose whether or not to take part in research or training.
10. All new patients will be asked to undergo a New Patient Health Check.
11. Patients will be offered a choice of consultant when referral is deemed necessary.
12. Any suggestions to improve services will be considered by the appropriate team members and a response given.
13. Complaints will be dealt with promptly in accordance with laid down procedures.
14. Access to a GP will be offered within 48 hours, or to another health professional within 24 hours. This may be over the telephone.
15. Patients between 16 and 75 years who have not attended a consultation or clinic appointment for three years can request an appointment for Health Care advice and treatment.
16. Repeat prescriptions will be available within 2 working days of request during normal working hours.

With these rights come responsibilities, and for patients this means:

1. Courtesy to the staff at all times, remember they are working under doctors’ orders. There is a zero tolerance policy for violence or abuse towards staff and other patients. The penalty violating this rule is immediate removal from the practice list.
2. To attend appointments on time or to give the practice adequate notice that they wish to cancel, lateness or non-attendance inconveniences other patients and wastes valuable appointment time. Patients continuously misusing the service will be removed from the list.
3. An appointment is for one person only, where another member of the family needs to be seen or discussed, another appointment should be made.
4. Appointments are for ten minutes, if you think you need a longer appointment please request this at the time of booking.
5. Home visits are for terminally ill or housebound patients only. Please bring children to surgery. If you speak to the triage doctor you may be able to be seen as a priority.
6. When patients are advised that repeat prescriptions are due for review they must make an appointment within 28 days.
7. Out-of-hours calls, e.g. evening, night and weekends, should only be made if they are felt to be a medical emergency. This also applies to Accident and Emergency Services. A medical emergency is where patients are seriously ill and access to a clinician will not wait until the following morning, or Monday morning in the case of a weekend emergency.

Zero Tolerance

The practice considers aggressive behaviour to be any personal, abusive and/or aggressive comments, cursing and/or swearing, physical contact and/or aggressive gestures.

The practice will request the removal of any patient from the practice list who is aggressive or abusive towards a doctor, member of staff, other patient, or who damages property.

All instances of actual physical abuse on any doctor or member of staff, by a patient or their relatives will be reported to the police as an assault.

Teaching & Training

This is a teaching and training practice and undergraduate students and GP registrars may be involved in your consultation.

Your permission to participate in consultations with these doctors will always be sought.