Patient Information Whose information is it anyway? Your health records

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1 Patient Information Whose information is it anyway? Your health records Derriford Hospital Derriford Road Plymouth PL6 8DH Tel:

2 Your health record We ask you for information about yourself so that you can receive proper care and treatment. This personal information forms part of your health record. In some cases we may obtain personal information relating to you from other sources, but only where they are authorised by you or where this information sharing is allowed by law. For example your GP will provide information on your behalf if you are referred for treatment. We keep your information, together with details of your care as an ongoing record of your healthcare. We may use some of this information for other reasons: helping to look after the health of the general public managing and planning the NHS by: making sure that our services can meet patients needs in the future preparing statistics on NHS performance and activity (where steps will be taken to ensure that you cannot be identified) and planning for future local services investigating complaints or legal claims helping staff to review the care they provide to make sure it is of the highest standard training and educating staff (but you can choose whether or not to be involved personally) research approved by the Local Research Ethics Committee (if anything to do with the research would involve you personally, you will be contacted to see if you are willing to take part - you will not be identified in any published results) auditing accounts and clinical care paying your doctor, nurse, dentist or other staff, and the hospital which treats you, for the care they provide providing admission details to the Department of Pastoral & Spiritual Care, unless you ask us not to do this. Where else is my information held? The NHS Central Register for England and Wales contains basic personal details of all patients registered with a general practitioner. The Register does not contain clinical information. The NHS Demographic Batch Service (DBS) contains information about all NHS-registered people in England and Wales. It holds the patient name, date of birth, (and for deceased people, date of death), sex, address and the GP with whom the patient is registered. It holds no clinical information and its purpose is to support the maintenance of patient and population registers, which are essential to providing effective and efficient patient care. The DBS is accessible only by NHS staff that have a legitimate need to know the information held on it. Access to it is strictly controlled and monitored. If a patient wishes to opt out of 2

3 having their data disclosed to NHS staff using the DBS, their records can be flagged as exdirectory. How do I know information about me will be kept in a confidential way? The Trust s computer systems employ robust security measures to help ensure that your data is protected from unauthorised access or modification, and accidental loss. Your manual records are also protected. Everyone working for the NHS has a legal, ethical and contractual duty to keep information confidential. Will you give my details to anyone? There are occasions when some details may be given to others: Quite clearly we cannot administer your care without the controlled sharing of your information amongst the direct care team. For example administration staff need to have limited access in order to schedule appointments. You may be also receiving care from other people such as your GP and Social Services. So that we can all work together for your benefit we may need to share some information about you where the Law requires it or with consent. If you are claiming against a third party, or applying for benefits, there may be times when a report about your condition may be made on your behalf. We will only do this with your permission. Sometimes the law requires us to pass on information, for example, to notify a birth or an infectious disease. Law courts can also insist that medical records are disclosed. With your permission, your relatives, friends and carers can be kept up to date with the progress of your treatment. We only ever pass on information about you if people have a genuine need for it. Whenever we can, we shall remove details which identify you. Anyone who receives information from us is also under a legal duty to keep it confidential. Can I see my health record? The Data Protection Act (1998) gives you the general right to apply to see or have a copy of any personal data held or anything written about you in your health record. The Access to Health Records Act (1990) gives a patient s representative the right to access the health records of that patient if they have died. Maximum fees for access and providing copies are set down by law - you can obtain details of the charges from the Legal Department. 3

4 Contacts For further information and application forms please write to, or telephone: Legal Department Plymouth Hospitals NHS Trust ITTC Building Tamar Science Park 1 Davy Road Plymouth PL6 8BX Tel: Fax: GP Records Contact the Practice Manager If you are in hospital your nurse can help you contact the appropriate people in these departments. Data controllers Each Trust and each GP Surgery act as Data Controllers for the purposes of the Data Protection Act 1998 Complaints/appeals If you believe we have not complied with the Act, either in responding to your request or in our general processing of personal information, and you have had no satisfaction from the contacts listed, you should first contact the Chief Executive of the Trust. Of course you always have the right to complain, appeal or raise your concerns with the Information Commissioner by writing to: The Information Commissioner Wycliffe House Water Lane Wilmslow Cheshire SK9 5AF Information Line: Internet: mail@dataprotection.gov.uk Further details This leaflet does not give a full explanation of the law. If it doesn t answer your questions or you would like more detailed information, please contact the Office of the Information Commissioner (see above). 4

5 Please note: The Freedom of Information Act does not permit the disclosure of medical records This leaflet is available in large print and other formats and languages. Please contact Patient Services Tel Date issued: August 2009 For review: 2011 Ref: D-80/Corp/TD/Whose info is it 5