Medical Records

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Medical Records

Your medical records are a life long history of your consultations, illnesses, investigations, prescriptions and other treatments. The doctor-patient relationship sits at the heart of good general practice and is based on mutual trust and confidence. The story of that relationship over the years is your medical record. Your GP is responsible for the accuracy and safekeeping of your medical records. You can help us to keep it accurate by informing us of any change in your name, address, telephone number or marital status and by ensuring that we have full details of your important medical history. If you move to anther area or change GP, we will send your medical records to the local Health Authority to be passed on to your new practice.

Your Right To Privacy

You have the right to keep your personal health information confidential between you and your doctor. This applies to everyone over the age of 16 years and in certain cases to those under sixteen. The law does impose a few exceptions to this rule, but apart from those (detailed in this information sheet) you have the right to know who has access to your medical records.

Who else has access to my Records?

There is a balance between your privacy and safety, and we will normally share some information about you with others involved in your health care, unless you ask us not to. This could include doctors, medical students, nurses, therapists and technicians involved in the treatment or investigation of you medical problems.

Our practice nurses, district nurses, midwives and health visitors will have access to your medical records when the information is relevant to your treatment.

Our practice staff have limited access to medical records. They need to notify the health authority of registration details and perform various filing and administrative tasks on the medical records.

All our doctors, nurses and staff have a legal, ethical and contractual duty to protect your privacy and confidentiality.

Where Else do we send Patient Information?

We are required by law to notify the Government of certain infectious diseases (e.g. meningitis, measles but not AIDS) for public health reasons. The law courts can also insist the GPs disclose medical records to them. Doctors cannot refuse to co-operate with the court without risking serious punishment.

We are often asked for medical reports from solicitors or insurance companies. These will always be accompanied by the patient’s signed consent for us to disclose any information unless otherwise stated. We will not normally release details about other people that are contained in your records (e.g. wife, children, parents’ etc.) unless we also have their consent.

Limited information is shared with the health authorities to help them organize national programmes for public health such as childhood immunizations, cervical smear tests and breast screening. GP’s must also keep health authorities up to date with all registration changes, additions and deletions. Social Services, the Benefits Agency and others may require medical reports about you from time to time. These will usually be accompanied by your signed consent to disclose information. Failure to co-operate with these agencies can lead to patients’ loss of benefits or other support, Life Assurance companies frequently ask for medical reports on prospective clients from the GP. These are always accompanied by your signed consent. GP’s must disclose all relevant medical conditions unless you ask us not to do so. In that case, we would have to inform the insurance company that you have instructed us not to make a full disclosure to them. You have the right, should you request it, to see reports to insurance companies or employers before they are sent.

How can I find out what’s in my Medical Records?

We are required by law to allow you access to your medical records, If you wish to see your records, please contact your GP for further advice. All requests to view medical records should be made in writing to the surgery. We are allowed by law to charge a fee to cover our administration and costs. We have a duty to keep your medical records accurate and up to date. Please feel free to advise us if any errors of fact, which have crept into your medical records over the years.

What we WILL NOT do

To protect your privacy and confidentiality, we will not normally disclose any medical information over the telephone or fax unless we are sure that we are talking to you. This means that we will not disclose information to your family, friends, and colleagues about any medical matters at all, unless we have your consent to do so. This also means that we will only disclose test results over the phone after efforts to ensure that we are talking to the right person. Finally, if you have any further queries or comments about privacy and your medical records, then please contact the practice manager or talk to your GP.