Your medical record

How we use medical information to help everyone

What we record at Lower Clapton Group Practice 

Information about you, your medical treatment and family background may be recorded, either on paper or in an electronic format. This is information is held to enable us to provide you with appropriate medical services.

All information about you is held securely and appropriate safeguards are in place to prevent accidental loss.

What you can do

Please read the rest of this leaflet in order to better understand how we use medical information about you. If you would like further information then please contact the Surgery using the details below:

The Practice Manager

Lower Clapton Group Practice

36, Lower Clapton Road

E5 0PQ

How we use your information

Doctors need to make notes about your diagnosis, medical history, medication and other information you may provide that is relevant to the treatment of your condition. We need this information in order to provide you with the best possible care.

Nurses and other health professionals may also need access to your medical record, and will also add their own notes as part of the overall package of healthcare provision you receive.

Secretaries and other administrative staff also need access to your records in order to book appointments; communicate with you, and ensure that referrals to secondary care are properly managed.

The Health Service

In order to manage the NHS some restricted information concerning treatment, prescribed drugs, vaccinations, numbers of patients seen, etc, is needed. Hospitals and general practices must provide this information in anonymised returns to the NHS. These returns do not include patient identifiable data and are summary in nature.

Medical research

Some medical research may require your direct involvement (especially if you are taking part in clinical trials). Your express consent will be necessary before researchers are given any access to your medical record.

Most research deals with summary data, and the information provided by the practice will not reveal any of your personal details. For example, the surgery provides the government with information on the number of flu vaccinations administered during the year. This information is summary in nature (no specific patient details are provided).

Managing the data

When you move from one Surgery to another we need to move your electronic medical record from system to system. We may also need to share electronic information with other medical professionals directly involved in your care. For example, your secondary care consultant or surgeon.

Occasionally, tests will need to be made on the data to check that is has been transferred correctly. These tests will only be made under strict conditions that ensure your confidentiality is protected.

Other Agencies

The NHS is not the only government service to provide you with the care you need. If may be necessary for us to provide information to other agencies directly involved in your care. Under these circumstances we will seek your consent before information in shared.

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.

How we protect your information

The sensitivity of patient information is well understood within the NHS. All staff and contractors are trained to respect their duty of confidentiality to you, and this obligation is written into all staff contracts and third party contracts.

We keep paper and electronic records in secure conditions to prevent unauthorised access. Wherever possible we remove references to personal details such as your name and address. We encrypt electronic information before it is transferred, and we also encrypt* any ‘back ups’ of the data we hold.

* (Encryption makes an electronic file unreadable without a secret password).

What else?

You can have a say in how the NHS uses information about you, and we are required by law to allow you access to your medical records. Please make any request for access in writing. An administrative fee will be charged to cover the cost of administration. If you want to find out more, or have any concerns, please contact the Practice Manager.

GDPR: National Data Opt-Out Programme – NHS Digital

National Data Opt-Out Programme – NHS Digital

https://digital.nhs.uk/services/national-data-opt-out-programme

Summary

We’re introducing a new tool that people can use to opt out of their confidential patient information being used for reasons other than their individual care and treatment. It will be secure and accessible and will be available from 25 May 2018.

The national data opt-out

NHS Digital is developing a new system to support the national data opt-out which will give patients more control over how identifiable health and care information is used. The system will offer patients and the public the opportunity to make an informed choice about whether they wish their personally identifiable data to be used just for their individual care and treatment or also used for research and planning purposes.

Choosing to opt-out

Patients and the public who decide they do not want their personally identifiable data used for planning and research purposes will be able to set their national data opt-out choice online. We will provide a non-digital alternative for patients and the public who can’t or don’t want to use an online system. Individuals can change their mind anytime. Existing Type 2 opt-outs (the option for a patient to register with their GP, to prevent their identifiable data leaving NHS Digital) will be converted to the new national data opt-out. Patients with type 2 opt-outs will be informed of this change individually.

Timescales

NHS Digital is developing the system now. Patients and the public will be able to use the system from 25 May 2018. All health and care organisations will be required to uphold patient and public choices by March 2020. The national data opt-out will be introduced alongside the new data protection legislation.

Information for health and care professionals

If you work in health and care, the introduction of the national data opt-out will mean you have two new areas of responsibility. You will need to be aware of the service in case patients ask you about it and in time you will be expected to uphold these preferences and advise patients. In the Resources section below there is an information pack (Pack E1) and readiness checklists, containing information about what organisations need to do now to be ready for the national data opt-out being available from 25 May 2018.

Advising patients

Everyone working in health and care needs to be aware of the national data opt-out so that they can inform and advise patients on where to go for more information about data use and the national data opt-out. The information shared by health and care staff will support patients to make an informed decision about how their personally identifiable data will be used.

Upholding patient preferences

Health and care professionals who send patient identifiable data to other organisations for reasons other than a patient’s individual care and treatment will need to know how and when to uphold a patient’s preference. More information will be provided on this in due course.

Resources

We’ve prepared presentations that can be edited to be relevant to your local settings, to help you inform the health and care professionals you work with about the national data opt-out.

Information packs

Pack A The NDG Review and Government Response Published March 2018

Pack B Taking the National Data Opt-out Forward Published March 2018

Pack C National Data Opt-out Approach Published March 2018

Pack D National Data Opt-out Operational Policy Published November 2017

Pack E1 Preparing for Implementation Published March 2018

Pack F Patient journey – coming soon
Pack G Fit with Data Protection Bill (GDPR) Published December 2017

We will provide more information and resources on these pages as the development of the new system progresses.

Organisation readiness checklists

These checklists – one for GP practices and one for other health and care organisations – can help you understand what your organisation should do to be ready for 25 May 2018.

Readiness checklist – GP practices
Readiness checklist – other organisations

Join the national data opt-out mailing list

Fill in the national data opt out team contact form to be added to our mailing list.

Background to the national data opt-out

The National Data Guardian, Dame Fiona Caldicott, recommended a new opt-out model for data sharing in her Review of data security, consent and opt-outs in 2016. The aim is to allow patients to make an informed decision about how their personal data will be used. It is part of a vision to improve patients’ trust and confidence in how data is looked after by the health and social care system. The National Opt-out ties in with other work on data security and making sure data is only used for the benefit of people’s health and care.

Accessible Information Standard

The Accessible Information Standard (AIS) is a new NHS England standard for NHS and adult social care organisations.

The aim is to ensure that people who have a disability, impairment or sensory loss, receive information that they can access and understand, for example in large print or via email.

This affects the practice in the following way – we will:

ASK  –  identify patients who have information or communication needs

RECORD  –  make a note of those needs in a standard way

ALERT  –  highlight the patient’s record, so their needs are clear

SHARE  –  where appropriate, share that information with other NHS and adult social care providers

ACT  –  aim to provide information to patients in an accessible way

You will notice that when you register at the practice, you will be asked about your information and communication needs.  Patients already registered here may be asked opportunistically.

PLEASE NOTE:  You do not have to wait for us to ask you.  If you have an information or communication need, you can tell the reception staff and they will note it on your medical record.

Website Accessibility Information

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Further help

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  • Have problems seeing the screen
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then we recommend you visit the BBC website My Web My Way, which provides advice on how to make your computer easier to use, whether you are a Windows, Mac or Linux user.