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Your doctor, nurse or any other health and social care professional needs to keep records on their interactions with you.
As information we collect about you and your health is very personal, it is important that you can be sure that such information is not passed on or used inappropriately. All information about you is kept secure and in strictest confidence. We only ever use or pass on information about you, if we have a genuine need to do so in your and everyone’s interests. We ask you for information about yourself so that you can receive proper care and treatment. We keep this information together with details about your care because it may be needed if we see you again. If we need to transfer your information we will always do this securely and where practicable remove personal details such as your name and address.
Everyone working for the NHS has a legal duty to keep information about you confidential. Anyone who receives information from us is also under a legal duty to keep it confidential. Sharing some types of very sensitive personal information is strictly controlled by law. Friends and relatives who make enquiries about you if you are an inpatient are not given specific details about your condition, unless you have agreed they can have more information
Your rights related to the use of information about you are protected by the Data Protection Act, the Caldicott Committee (a group which set rules about using and protecting patient information) and the Human Rights Act. The Trust has to ensure information is used appropriately in order to meet these requirements.
The Data Protection Act (2018) means that:
The name Caldicott is taken from the committee, chaired by Dame Fiona Caldicott, which was set up by the Department of Health and the British Medical Association in 1997 to look at how patient identifiable information was handled in the NHS. The Committee’s report proposed that all NHS organisations should appoint a ‘Guardian’ to oversee the use and sharing of clinical information within their organisations.
The Caldicott Committee (Using and Protecting Patient Information) recommended that the use of patient identifiable information should be regularly justified and routinely tested against the principles developed in the Caldicott Report. A further Caldicott review was undertaken (Caldicott2) in 2013 the outcome of which was an additional Principle(7)
The Human Rights Act (1998) Article 8 is the “Right to respect for private and family life, home and correspondence”.
The way information about patients is updated; stored; the form it is collected in; the way it is accessed and kept confidential are relevant issues to the Act and have to be managed so that Article 8 of the Act is met.
The Care Record Guarantee sets out our obligations for protecting and safeguarding your information, especially if we need to share this with other organisations such as social services or education.
If we do need to share information with other services we will tell you about this and agree it with you beforehand. If you do not wish personal data that we hold about you to be used or shared in the way that is described in this leaflet, please discuss the matter with us. You have the right to object, but this may affect our ability to provide you with care or advice.
If you are not able to make decisions about sharing information, a senior health care professional involved in your care may consider it to be in your best interests to share information. This judgement will take account of the views of relatives and carers and any views you have already recorded.
Information is kept in a variety of computer and written records. At the moment most patients will have a physical paper set of case notes, and an Electronic Patient Record. The Trust is progressing towards a completely electronic system and where possible phasing out written records. The types of information held will remain the same, but will be stored electronically rather than on paper. Until this happens, the electronic record is updated, and any paper notes generated will be filed after each episode of care (eg outpatient clinic, hospital stay etc). The move to electronic records provides a number of benefits to patients and those providing care. Electronic records may be accessed immediately by many staff and access is strictly controlled and monitored.
There are a number of elements which make up the Electronic Patient Record (EPR), including the two main systems, which are called MEDITECH and SystmOne. Depending on what care you are accessing will mean your information is recorded on one or both of these systems.
These systems keep records of all patients’ clinical and administrative records. They hold information on outpatient attendances, inpatient admissions, emergency department attendances and care in the community. Records include details relating of your condition, of the clinical care provided and Patient Confidentiality 8 Patient Confidentiality correspondence with your GP. The many different types of information which are collected include:
If you are admitted to a Trust facility, some additional information is collected. These include:
Clinical staff record details of your medical history, symptoms, medication, findings on examinations, treatments and follow up information every time you are seen by a doctor. This information is needed so that it will be available the next time you are seen.
In addition to doctors, other health care professionals involved in the care of patients may write in the medical record.
Nursing records are the records of nursing care you receive during an admission to hospital.
Another type of record is a 'Care Pathway'. This is a complete patient record for a patient with a specific diagnosis and it is used for recording all the care the patient has received, by doctors, nurses, and any other health care professionals. This is filed in the medical record when the patient is discharged from hospital.
Some departments keep their own records which are separate from the main medical record. Over time, most stand-alone records will be incorporated within the Electronic Patient Record.
Separate records are kept by departments such as:
We may use some patient information to see that the NHS runs efficiently, plans for the future, trains its staff, pays its bills and can account for its actions. In general, information used for any of these purposes is anonymised, but there may be occasions where patient identifiable data is required.
Information about patients is used in planning the work of the Trust, by monitoring the numbers of patients on waiting lists for outpatient appointments, for admission, and operations. It is also used to monitor the work undertaken by the Trust and assess the costs. Data is not identifiable in the majority of cases.
Patient information is used to investigate untoward incidents. This is so that problems can be identified and actions taken to ensure they do not happen again. Information is only used on a 'need to know' basis and will not be used where it is not necessary.
Patient information about specific groups of patients is used for audit purposes. The information used is information related to the specific aspects of care the audit is examining, and is carried out to ensure patients receive good quality care based on standards of good practice. All patient information used in audit is anonymised to ensure confidentiality is maintained.
Information about your health may be accessed to determine your eligibility to participate in research. Your health information may be used in research with appropriate consent. This may be in observational studies investigating patients with the same or similar health problems or it may be in formal drug or treatment trials. In both cases you will have been notified and provided your consent.
Information may also be needed to help to educate future clinical staff and to carry out medical and other health research for the benefit of everyone. We shall remove details that identify you. If any pictures of you are required for use, you will be asked to give your consent.
Medical information about you may be used for education in a number of ways. The management of some patients may be discussed at specialty meetings to obtain opinions of colleagues, or where there has been a problem, to ensure lessons are learned so this does not happen again.
Information may be used in teaching medical students, junior doctors and other healthcare professionals about health problems and treatments.
Some statutory central information has to be provided for Department of Health statistical purposes.
Some information has to be provided to others because it is “Notifiable Information”. This includes information on child abuse, and certain “Notifiable” infectious diseases, for example meningitis, salmonella infections, and other infectious diseases, to help us protect the health of the public generally. Sometimes, the law requires us to pass on information: for example, to notify a birth or a death.
We may transfer information to other organisations with legitimate rights. These are:
It is important that the information we collect or hold about you is as up to date and accurate as possible. This helps us provide the best clinical care to you and also to make sure that if we need to contact you or send you information, it will be directed to the right person or place. You can help us by telling us if:
The Data Protection Act gives you the right to see your health records. These can be the records made by a doctor, a nurse or any other health professional. For further information and application forms, contact firstname.lastname@example.org or 01709 424257.
The Caldicott Guardian is a senior person in the Trust who is responsible for protecting the confidentiality of your information and for making sure it is shared lawfully and properly. The Caldicott Co-ordinator can be contacted on 01709 427637.