Your health records
This page tells you about what we do with the information that we hold about patients, and who we might share it with.
Sharing information with us
We ask you for information so that we can give you care and treatment.
It is important that our staff know as much about your mental health and physical health needs as possible. We encourage you to be a “guardian of your own safety” by giving us as much information as possible. That may include information about allergies, or whether you are pregnant, whether you are taking any medications or using alcohol or drugs.
What sort of information do we need?
The records we keep may include details such as your name, address, date of birth and next of kin; visits you have made to our services; details and records about the treatment and care you need or have received; results of investigations, such as laboratory tests; and relevant information from other health professionals, relatives or those who care for you and know you well.
Why we collect information about you
We keep this information so that we have accurate and up-to-date information to assess your health and decide what care you need when you visit in the future.
Information about you may also be used for the following reasons:
- making sure our services meet your needs in the future;
- helping staff to review the care they provide to ensure it is of the highest standard;
- investigating complaints or legal claims;
- paying your doctor, nurse or other staff, and the hospital which treats you for the care they provide;
- preparing statistics on NHS performance and activity (where steps will be taken to ensure you cannot be identified);
- managing and planning the NHS; and
- looking after the health of the general public.
Your information may also be used for training and educating staff or approved research and you would be contacted to see if you are willing to take part personally in either of these instances.
Where information is used for statistical purposes strict measures are taken to ensure that individuals cannot be identified. Where it is not possible to use anonymised information, personally identifiable information may be used for essential NHS purposes. These may include research and auditing services. This would only be done with your consent, unless the law requires information to be passed on to improve public health.
How you can get access to your own health records
Under the Data Protection Act 1998 you have a right to access your health records. If you want to see them you should make a request to your health professional where you are, or have been, treated. You can also request to receive copies of letters written by one health professional to another about you.
Documentation that might be copied to you includes:
1. letters between members of the team looking after you and GPs, other doctors, therapists or other health care professionals;
2. letters to other agencies such as social services, housing or benefits agencies, employers or insurance companies; and
3. copies of care plans, assessments or referral forms.
All the information in these documents should have already been discussed with you. However, it is important to remember that these letters provide other health professionals with clinical information about your treatment and care. Therefore you may find that some of the language includes technical terms.
Who can I talk to if I have questions about a letter that I receive?
A member of your healthcare team will write any correspondence you may receive.
Please contact the person who sent the letter if you have any questions.
How will I receive copies of letters?
You can be sent a copy through the post or you can collect a copy in person. Please make sure we have your correct address details and that you are happy for us to send letters to your address. It is very important that you let us know any changes to your address, telephone number or family doctor.
As a carer can I receive copies of letters?
Providing we have written consent from the person you are caring for, we can send you copies of letters.
My child is the patient, so who will receive copies of letters?
Parents of children under 16 may receive copies of letters. Young people aged 16 and 17 are classed by law as adults and they have the right to confidentiality. Therefore, if a 16 year old wishes a medical practitioner to keep this treatment confidential then that wish will be respected.
How we keep your records confidential and secure
Everyone working for the NHS has a legal duty to keep information about you confidential and secure.
You may be receiving care from other people as well as the Trust, such as social services staff. On these occasions we may need to share some information about you so we can all work together for your benefit. We only ever use or pass on information about you if others involved in your care have a genuine need for it. When we pass on any information we ensure it is kept confidential and secure.
We do not disclose your information to third parties (eg the police) without your permission. However occasionally there are exceptional circumstances that mean we have to, such as when the health or safety of others is at risk or where the law requires information to be passed on. If we do need to disclose your information we ensure it is kept secure. If you ask us not to share information with others, we will respect your decision. If we feel that your decision is not in your best interests, we will discuss this with you.
Any organisation that receives information from us is also under a legal duty to keep it confidential and secure.
We are required by law to report certain information to the appropriate authorities. If we encounter infectious diseases that may endanger the safety of others such as meningitis or measles (but not HIV/AIDS) or where a formal court order has been issued. This is only provided after formal permission has been given by a qualified health professional.
The Caldicott Guardian is a senior practitioner appointed to ensure that the information about services users is handled in a confidential manner by the Trust. The Caldicott principles have been incorporated into the NHS Confidentiality Code of Practice.
If you have any queries or would like further infomation, please contact Robert Paley in the first instance on email@example.com or 0300 555 1201 ext. 64393.
Our partner organisations
The Trust works closely with a number of other NHS organisations. These are known as our principal partner organisations, as listed below, and information may be shared with them:
Strategic Health Authorities;
Primary Care Trusts;
General Practitioners (GPs); and
Your information may also, subject to strict agreements describing how it will be used, be shared with:
NHS Common Services Agencies such as dentists, ophthalmic services etc;
Voluntary Sector Providers; and
Private Sector Providers.