When you see a doctor, or go to hospital, a record of your care is kept. Your records include details such as your name, address, contact details and date of birth. It is importatnt that you tell us if any of your details change. Your records also contain facts about your health, including appointments, treatments and test results. They may also contain information based on the professional opinion of the staff caring for you.

Your records are used to:

Make sure the staff caring for you have accurate, up to date information to help them decide the best possible care and treatment for you.
Share information about the treatment you need with other staff and organisations who are caring for you to ensure you are properly looked after.
Make sure that your concerns can be properly looked into if you have a complaint
Make sure we have an accurate record if we have to review your care.

Information from your records with your name and other personal details removed, may be used to manage health services including:
To monitor and improve the quality of care received by patients
To make sure that treatments and services meet the needs of local communities. This may include sharing information with other organisations.
Training and educating staff

Keeping your information confidential

Everyone working for the NHS has a legal duty to maintain the highest level of confidentiality. All staff are instructed on handling information confidentially. Computer systems are designed with a number of security features. Your information will be stored, managed and used with the greatest possible care. To make sure you receive all the care and treatment you need we might share relevant information about you with other organisations, either via paper or by access to shared computer systems Other organisations include:

Your General Practice, Pharmacies and Dentists
Hospitals, Walk in Centres, Out of Hours Doctors, NHS Direct
Community Services (nurses, midwives and therapists)
Local Authority Departments, including Social Services, Education and Housing
Voluntary Care organisations
Private Sector organisations (private hospitals, care homes, hospices)

We will talk to you to make sure you are aware of any information we share. You can raise any concerns you may have at any time. If we are unable to talk to you we will only share information where it can be shown to be in the best interests of yourself or another individual, to ensure quality of care or to protect from harm. When information is shared, it is passed securely and kept confidential by the people who receive it. It will only be used for the purpose for which it has been shared.

With your consent information can be shared with relatives, partners or friends who may act as a carer for you. Sharing information can help your family or carer understand the support you require. During an assessment or review of your care, we will ask what information you want shared with your family or carer. We will record your views in our records.

Sharing your information without your consent

We will normally inform you and ensure you are happy for your information to be shared, but there are times when we may need to share your information without your consent. This will only happen where we are legally required to do so, or the law allows us to do so in order to protect you or other people. Such situations include:

Where there is a risk of harm or abuse to you or other people
Where a serious crime, such as assault, is being investigated or where it could be prevented
To control infectious diseases such as meningitis, tuberculosis (TB) or measles
Notification of a birth
Where the courts have made a formal order in relation to a court case

We will try to inform you if we share your information without your consent.

Research

Research is only carried out when it has been approved by the Local Research Ethics Committee. Your health record can also help us with research studies. Organisations that have provided care for you may invite you to participate in studies on behalf of research programmes You are under no obligation to take part. No health information will be passed to researchers unless you choose to take part.

You will not be identified in any publication without your consent. If you do not wish to have information used in this way, please talk to the person in charge of your care.

How we record your information

Information is recorded on paper and computer systems. The NHS is introducing new computer systems to improve accuracy and availability of information to those treating you. Computers enable infomation to be shared across organisations, giving staff that care for you the right information at the right time. A great deal of security is put into systems and how they are run to ensure your information is confidential. If you have questions about how your information is protected on computer systems, please ask. An explanation of security will be given and you will be informed of options you may have to restrict access.

Information to manage the NHS

The NHS Personal Demographics Service for England and Wales contains basic personal details of all patients registered with a General Practitioner (GP) in order to manage administration of practice lists.

So that the NHS can manage and plan services, some information about you is sent to the Primary Care Trust (PCT) responsible for your care, and to the Department of Health. As far as possible this information will not identify you. The information is used for a variety of purposes such as to pay organisations for the care they provide, investigate complaints or untoward incidents and to look after the health of the general public.

Further use of centrally held information is strictly controlled by the Department of Health and advisory bodies such as the Patient Information Advisory Group.

Further information and accessing your records

Each organisation, such as a General Practice or Hospital that provides care for you will hold and control your information. If you would like to know more about how we use your information you can:

Speak to the person in charge of your care
Raise a query with the Patient Advice and Liaison Service (PALS). They will ensure you are provided with a detailed response.

If you wish to see or have a copy of your records, write to the 'Records Manager' of the organisation where you are being, or have been treated. You may be charged an administration fee. You should be aware that in exceptional circumstances some information may be withheld to protect you from undue harm, or where a third party is involved.

NHS Connecting for Health is supporting the NHS introduce new computer systems and services. These will help the NHS to deliver better, safer care for patients. For more information about this, visit the website www.connectingforhealth.nhs.uk.

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