Access to Your Medical Record
What is in my Medical Record?
Your medical record contains notes taken during every consultation you have had with a doctor or nurse at your practice or community service. Your record is also likely to include copies of any letters you have written and notes relating to any phone calls made with the service that you have been in contact with. Your record will also contain copies of letters from other hospitals and departments, including mental health assessments if you have ever had one. The time period covered by your electronic medical record can vary from one GP practice to another, but detailed information extending right the way back into your childhood may be included. All of this information is sometimes known as "Your Detailed Care Record."
How do I access my Medical Record?
Terms Used in this section
Data Controller - This is the controller of the data and the system, as defined in the Data Protection Act. In this case the Controller is the Partnership.
Data Subject - This is the person whose information is within the system, and who has rights of access as determined under the Act.
Third Party - A person or body other than the Data Subject who requests access, or to whom information may be provided.
Access - Data Subject
The General Data Protection Regulations specify the rights of access of the Data Subject.
All requests for access must be in writing to the Business Manager.
A response will be provided as soon as possible, and in any event within 28 days. Where an application is declined, a reason will be given. In some circumstances, some parts of your record may be withheld.
Access to my Medical Record Online
It is now possible to access some elements of your medical records online. For more information please click here.
Who can see my Medical Record?
All members of our Practice Team have access to your medical record to the level that is required for them to perform their job role. In addition to this there are a number of different NHS schemes involving the sharing of medical records and we have included information on these, including how you may opt out, below.
Enhanced Summary Care Record (ESCR)
What is a Summary Care Record? (also know as an SCR)
Your basic Summary Care Record is a short summary of your GP medical record that includes a list of medications you are taking and your allergies or bad reactions to medicines.
Version 2 (Enhanced Summary Care Record) includes all of the above PLUS additional information that can include information about the management of any Long Term Conditions such as Diabetes, Heart Conditions etc, your relevant medical history including why you take a particular medicine or any clinical procedure you have had, any specific communication needs or preferences about your future care and a list of your Immunisations.
You will already have a basic SCR unless you opted out but you will need to give specific consent for an SCR version 2. If you would like to give consent for the additional information to be added to your SCR please contact our reception team.
Your SCR can be viewed by other health and care staff who care for you when you are away from home. This can speed up your care and make sure you are given the correct treatment and medication. The healthcare staff will have been given the right levels of security access will always ask your permission to look at your SCR (except in an emergency, where you are unconscious for example).
When an SCR would be useful:
- in an emergency
- when you're on holiday
- when your surgery is closed
- at out-patient clinics
- when you visit a pharmacy
Who would benefit from an SCR with additional information?
- Frail patients who can give consent to out of hours or emergency health care staff, making unwanted admission less likely
- Patients with physical or other disabilities who will benefit from recording any specific communication or health needs
- Patients with carers whose details they want to share
- Non-English speakers
- Patients planning for end of life who can share information about Lasting Power of Attorney or advance care decisions
Enhanced Summary Care Record Patient Video
The Enhanced Data Sharing Model (EDSM)
The EDSM is designed to make it easier for patients to have greater control over their own records. By recording two different sharing consents in the patient record, 'sharing in' and 'sharing out', the decision not to share sits with the patient. 'Sharing out' controls the information recorded at the practice that is shared to other organisations. 'Sharing in' controls the information that can be viewed by the practice that has been recorded at another SystmOne organisation. The model works on a patient-by-patient basis, which means that if you move to a different area, you will remain on the EDSM model.
At this practice your GP records are made available for other health care professionals involved in your care to access. We feel this is in your best interest. Please be assured that no one outside of this practice will access your records without your verbal consent each time you are seen.
If you do not wish this to happen then it is important that you let us know by telephone, in writing, by clicking here or by logging in to your SystmOnline account by clicking here so that we can mark it on your record.
What is risk stratification?
There are two kinds of risk stratification:
The first kind is a process for identifying some patients within a Practice who might benefit from extra assessment or support with self-care because of the nature of their health problems. The process is a mixture of analysis of information by computer followed by review of the results by a clinical team at the Practice.
The analysis can, for example, help predict the risk of an unplanned hospital admission so that preventative measures can be taken as early as possible to try and avoid it. In the end, it is the clinical team of the GP Practice that will decide how your care is best managed.
The second kind is a process for identifying patterns of ill health and needs across our local population. This will be done by pulling together all the information in an anonymised file (where your identity has been removed) to look at patterns and trends of illness across Leicester, Leicestershire and Rutland as a whole. This will help our Public Health Department and those in the NHS who are responsible for planning and arranging health services across Leicester, Leicestershire and Rutland (known as commissioners) better understand the current and possible future health needs of the local population. This will help them make provision for the most appropriate health services for the people of this area. This group of staff will not be able to identify you as an individual under any circumstances.
In both cases secure NHS systems and processes will protect your health information and patient confidentiality at all times.
What information about me will be analysed?
The minimum amount of information about you will be used. The information included is:
- GP Practice and Hospital attendances and admissions
- Medications prescribed
- Medical conditions (in code form) and other things that may affect your health such as height, weight for example.
How will my information be kept secure and confidential?
Information from your GP record will be sent via a secure computer connection to a special location called a 'safe haven' at NHS Arden and Greater East Midlands Commissioning Support Unit (NHS Arden & GEM CSU) in Leicester This safe haven carries special accreditation from the NHS. It is designed to protect the confidentiality of your information. There are strict controls in place. It enables information to be used in a way that does not identify you. The GP Practice remains in control your information at all times.
Before any analysis starts, any information that could identify you will be removed and replaced by a number. The analysis is done by computer. The results are returned to the GP Practice. Only your GP Practice can see the results in a way that identifies you.
What will my GP Practice do with the analysis?
The results can help the clinical team decide on some aspects of your future care. For example, if the clinical team at the Practice think that you might benefit from a review of your care, they can arrange this. You may then be invited in for an appointment to discuss your health and treatment. If the Practice thinks you might benefit from referral to a new service, this will be discussed with you firstly.
What should I do if I have further questions about risk stratification?
Please ask the Practice staff if you can speak to someone in more detail.
What if I want to opt out?
If you do not wish this to happen then it is important that you let us know by telephone, in writing or by clicking here so that we can mark it on your record.
Sharing for NHS Research and Planning
Your health records contain a type of data called confidential patient information. This data can be used to help with research and planning.
You can choose to stop your confidential patient information being used for research and planning. You can also make a choice for someone else like your children under the age of 13.
Your choice will only apply to the health and care system in England. This does not apply to health or care services accessed in Scotland, Wales or Northern Ireland.
Information: This information is also available in other languages and formats.
What is confidential patient information
Confidential patient information is when 2 types of information from your health records are joined together.
The 2 types of information are:
- something that can identify you
- something about your health care or treatment
For example, your name joined with what medicine you take.
Identifiable information on its own is used by health and care services to contact patients and this is not confidential patient information.
How we use your confidential patient information
Your individual care
Health and care staff may use your confidential patient information to help with your treatment and care. For example, when you visit your GP they may look at your records for important information about your health.
Research and planning
Confidential patient information might also be used to:
- plan and improve health and care services
- research and develop cures for serious illnesses
You can stop your confidential patient information being used for research and planning. Find out how to make your choice.
If you're happy with your confidential patient information being used for research and planning you do not need to do anything.
Any choice you make will not impact your individual care.