Practice Policies & Patient Information
Access to Health Records
Doctors have always had the discretion to allow patients to see their health records and to share information where appropriate with the carers of children and incapacitated adults. Additionally in recent years Acts of Parliament have given certain statutory rights of access to records. None of the legislation prevents doctors from informally showing patients their records or, bearing in mind duties of confidentiality, discussing relevant health issues with carers.
The implementation of data protection legislation in early 2000 changed patients’ statutory rights of access to their health records. The purpose of this guidance is to set out in some detail the legal requirements on doctors as holders of health records. This summary highlights the main points.
How do I access my medical records?
- Please use the NHS app to access your medical record electronically.
- If you have any problems, please contact our IT team by emailing [email protected]
What records are covered?
All manual and computerised health records about living people are accessible under the Data Protection Act 1998.
Does it matter when the records were made?
No, access must be given equally to all records regardless of when they were made.
Does the Act cover all of the UK?
Yes.
Who can apply for access?
Competent patients over the age of 18 may apply for access to their own records, or may authorise a third party, such as their lawyer, to do so on their behalf. Parents may have access to their child’s records if this is in the child’s best interests and not contrary to a competent child’s wishes. People appointed by a court to manage the affairs of mentally incapacitated adults may have access to information necessary to fulfill their function.
Must copies of the records be given if requested?
Yes, patients are entitled to a copy of their records, for example a photocopy of paper records or print out of computerised records.
Are there any exemptions?
Yes, the main exemptions are that information must not be disclosed if it:
- is likely to cause serious physical or mental harm to the patient or another person; or
- relates to a third party who has not given consent for disclosure (where that third party is not a health professional who has cared for the patient).
Can a fee be charged?
Not under the new GDPR regulations. A fee may be charged for repetitive or excessive requests, these limits are set by the Surgery.
What about access to the records of deceased patients?
The Data Protection Act 1998 only covers the records of living patients. If a person has a claim arising from the death of an individual, he or she has a right of access to information in the deceased’s records necessary to fulfill that claim. These rights are set out in the Access to Health Records Act 1990 or Access to Health Records (Northern Ireland) Order 1993. The provisions and fees are slightly different from those in the Data Protection Act.
In these circumstances please contact our Non-NHS Team by emailing [email protected]
Latest guidance on confidentiality and on sharing information with relatives and carers is available from the BMA’s Medical Ethics Department.
Accessible Information Standards Policy
The aim of the accessible information standard policy is to make sure that people who have a disability, impairment or sensory loss get information that they can access and understand, and any communication support that they need.
As part of the accessible information standard, organisations that provide NHS or adult social care must do five things. They must:
- Ask people if they have any information or communication needs, and find out how to meet their needs.
- Record those needs clearly and in a set way.
- Highlight or flag the person’s file or notes so it is clear that they have information or communication needs and how to meet those needs
- Share information about people’s information and communication needs with other providers of NHS and adult social care, when they have consent or permission to do so.
- Take steps to ensure that people receive information which they can access and understand, and receive communication support if they need it, such as from a British Sign Language interpreter.
If you need any of the information we send out to you in an alternative format (e.g. large print or easy read) or if you need help in communicating with us (e.g. use British sign language or are hard of hearing) then please telephone or email us to let us know, so we can update your records.
NHS Accessible Information Standard update July 2015 BSL & subtitles
More information about the standard can be found at NHS England – Accessible Information
Chaperone Policy
Balham Park Surgery is committed to providing a safe, comfortable environment where the safety of patients and staff is of paramount importance. A key issue to be addressed is the need for patients experiencing consultations, examinations and investigations to be safe and to experience as little discomfort and distress as possible. Equally health professionals are at an increased risk of their actions being misconstrued or misrepresented if they conduct examinations where no other person is present and must minimise the risk of false accusations of inappropriate behaviour.
This policy presents principles and outlines the procedures that should be in place for appropriately chaperoning patients during examinations, investigations and care. It is largely based on the Model Chaperone Framework published by the NHS Clinical Governance Support Team, in June 2005.
Responsibilities
Guidance on chaperoning is for the protection of both patients and healthcare professionals. All clinicians and others working on their behalf have a duty to consider chaperoning issues as they relate to their work and to work in accordance with the following principles.
Principles of good Practice
Patients may find any examination distressing, particularly if these involve the breasts, genitalia or rectum (known as “intimate examinations”). Also consultations involving dimmed lights, close proximity to patients, the need for patients to undress and being touched may make a patient feel vulnerable.
Chaperoning may help reduce distress, but must be used in conjunction with respectful behaviour which includes explanation, informed consent and privacy.
Consent
In attending a consultation it is assumed that a patient is seeking treatment and therefore is consenting to necessary examinations. However, before proceeding with an examination healthcare professionals should always seek to obtain, by word or gesture, some explicit indication that the patient understands the need for examination and agrees for it to take place.
What is a chaperone?
A chaperone is present as a safeguard for both parties (patient and healthcare professionals) and is a witness to the conduct and the continuing consent of the procedure.
The precise role of the chaperone varies depending on the circumstances. It may include providing a degree of emotional support and reassurance to patients but more commonly incorporates:
- Providing protection to healthcare professionals against unfounded allegations of improper behaviour.
- Assisting in the examination or procedure, for example handing instruments during IUCD insertion
- Assisting with undressing, dressing and positioning patients
Under no circumstances should a chaperone be used to reduce the risk of attack on a health professional.
Who may chaperone?
Chaperones may be termed ‘formal’ and ‘informal’.
Informal chaperones
Many patients feel reassured by the presence of a familiar person and this request in almost all cases should be accepted. This informal chaperone may not necessarily be relied upon to act as a witness to the conduct or continuing consent of the procedure. Under no circumstances should a child be expected to act as a chaperone. However, if the child is providing comfort to the parent and will not be exposed to unpleasant experiences it may be acceptable for them to stay. It is inappropriate to expect an informal chaperone to take part in the examination or to witness the procedure directly.
Formal chaperones
A ‘formal’ chaperone implies a clinical health care professional, such as a nurse or a healthcare assistant. This individual will have a specific role to play in terms of the consultation and this role should be made clear to both the patient and the chaperone. It is important that chaperones have had sufficient training to understand the role expected of them and that they are not expected to undertake a role for which they have not been trained for.
Protecting the patient from vulnerability and embarrassment means that the chaperone would usually be of the same sex as the patient. There will be occasions when this is difficult to achieve. If the patient is requesting a male chaperone then a male GP can be called upon to act as the chaperone or the patient can be offered to rebook their appointment with a male GP.
The patient should always have the opportunity to decline a particular person as a chaperone if that person is not acceptable to them for any justifiable reason.
Training for chaperones
Members of staff who undertake a formal chaperone role should undergo training.
This should include an understanding of:
- What is meant by the term chaperone
- The specific details of different types of intimate examinations
- The rights of the patient
- Their role and responsibility
- Policy and mechanism for raising concerns
Introduction of new clinical staff should include the above training.
Offering a chaperone?
The relationship between a patient and healthcare professionals is based on trust. A practitioner may have no doubts about a patient they have known for a long time and feel it is not necessary to offer a formal chaperone. However this should not detract from the fact that any patient is entitled to a chaperone if they feel one is required.
It is good practice to offer all patients a chaperone of the same sex for any examination or procedure. If the patient is offered and does not want a chaperone it is important to record that the offer was made and declined.
Staff should be aware that intimate examinations might cause anxiety for both male and female patients whether or not the examiner is of the same gender.
If a chaperone is refused, a healthcare professional cannot usually insist that one is present. However, there may be cases where the practitioner may feel unhappy to proceed, for example where there is a significant risk of the patient displaying unpredictable behaviour, or making false accusations. In this case, the practitioner must make his/her own decision and carefully document this with the details of any procedure undertaken.
Where a chaperone is needed but not available
If the patient has requested a chaperone and none are available at that time the patient must be given the opportunity to reschedule their appointment within a reasonable timeframe (this may include simple waiting in the practice until a member of staff is available). If the seriousness of the condition would dictate that a delay is inappropriate then this should be explained to the patient and recorded in their notes. A decision to continue or otherwise must be jointly reached. In cases where the patient is not competent to make an informed decision then the healthcare professional must use their own clinical judgement and be able to justify this course of action. The decision and rationale should be documented in the patient’s notes.
It is acceptable for a healthcare professional to perform an intimate examination without a chaperone if the situation is life threatening or speed is essential in the care or treatment of the patient. This should also be recorded in the patient’s notes.
Issues specific to children
Children and their parents or guardians must receive an explanation of the procedure in order to obtain their co-operation and understanding. If a minor presents in the absence of a parent or guardian the healthcare professional must ascertain if they are capable of understanding the need for an examination.
In these cases it is advisable for a formal chaperone to be present for any intimate examinations.
In situations where abuse is suspected great care and sensitivity must be used to allay fears of repeat abuse. In these situations healthcare professionals should refer to the local child protection policies and seek advice from the Child Protection Lead/Team as necessary.
Issues specific to religion, ethnicity, culture and sexual orientation
All patients undergoing examinations should be allowed the opportunity to limit the degree of nudity by, for example, uncovering only that part of the anatomy that requires investigation. Some patient’s ethnic, religious, cultural background and sexual orientation can make intimate examinations particularly difficult. For example, Muslim and Hindu women may have a strong cultural aversion to being touched by men other than their husbands, or a lesbian woman or likewise a gay man may possibly have an aversion to intimate examinations being performed by the opposite gender. These considerations should be taken into account and discussed, not presumed. We must recognise that each individual has very different needs and before the procedure these should be mutually agreed with the healthcare professional.
Issues specific to people with learning difficulties and mental health problems
For patients with learning difficulties or mental health problems that affect capacity, a familiar individual such as a family member or carer may be the best chaperone. A simple and sensitive explanation of the technique is vital. This patient group is a vulnerable one and issues may arise with physical examination.
Adult patients with learning difficulties or mental health problems who resist an examination or procedure must be interpreted as refusing to give consent and the procedure must be abandoned. In life-saving situations the healthcare professional should use their clinical judgement. Where possible the matter should be discussed with a member of the Mental Health Care Team.
Non English speaking patients
In the situation of a non English speaking patient being examined the use of an independent interpreter should be enlisted. The use of a formal chaperone may still be appropriate with the interpreter in the room. A family member or interpreter should not be used as a formal chaperone.
Sedation
Should a patient require sedation for a particular procedure then it is mandatory that a chaperone must be present throughout and whilst they have fully recovered from the effects of the sedation. This is necessary because not only is the patient rendered more vulnerable, but also their understanding of events or recollection may be impaired. Hallucination may also occur.
Lone working
Where a healthcare professional is working in a situation away from other colleagues, for example during a home visit, the same principles for offering and use of chaperones should apply. The healthcare professional may be required to risk assess the need for a formal chaperone and should not be deterred by the inconvenience or complexity of making the necessary arrangements. In all instances the outcome must be documented.
Patient confidentiality
In all cases where the presence of a chaperone may intrude in a confiding clinician-patient relationship their presence should be confined to the physical examination. Communication between the healthcare professional and the patient should take place before and after the examination or procedure.
Non English speaking patients
In the situation of a non English speaking patient being examined the use of an independent interpreter should be enlisted. The use of a formal chaperone may still be appropriate with the interpreter in the room. A family member or interpreter should not be used as a formal chaperone.
Sedation
Should a patient require sedation for a particular procedure then it is mandatory that a chaperone must be present throughout and whilst they have fully recovered from the effects of the sedation. This is necessary because not only is the patient rendered more vulnerable, but also their understanding of events or recollection may be impaired. Hallucination may also occur.
Communication and record keeping
The key principles of communication and record keeping will ensure that the healthcare professional and patient relationship is maintained and act as a safeguard against formal complaints, or in extreme cases, legal action.The most common cause of patient complaints is the failure in communication between both parties, either in the practitioner’s explanation or the patients understanding in the process of examination or treatment. It is essential that the healthcare professional explains the nature of the examination and offers them a choice whether to continue. Chaperoning in no way removes or reduces this responsibility. Details of the examination including the presence or absence of a chaperone and the information given must be documented in the patient’s clinical record. The records should make clear from the history that the examination was necessary. In any situation where concerns are raised or an incident has occurred this should be dealt with immediately in accordance with the Incident Reporting Procedure.
Complaints
The complaints procedure is designed to encourage patients at these practices to voice concerns, whether clinical or administrative, with the assurance that they will be taken seriously and treated confidentially. We seek to guarantee a swift response which addresses issues raised, and to demonstrate our willingness to review and change if appropriate the systems we have in place or services that we provide.
Please read out guidance on our complaints procedure following the link below:
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TELL US WHAT YOU THINK!
HAVE YOU GOT A SUGGESTION, COMPLIMENT OR COMPLAINT?
At Balham Park Surgery, we want to provide you withg the very best of services. To do this we need to know your views.
Please complete the following form if:
- You want to let us know what you think about our sevvice
- You want to tell us when we get things right.
- You think we have made a mistake, or we have not given the service you expect and you want to make a complaint but do not wish to follow the formal process, or do not have time to speak to us but you would like us to be aware.
Data Protection and Security Information
Balham Park Surgery Data Privacy Notice
Click here to view our Data Privacy Notice
NHS DATA OPT-OUT
The National Data Opt-Out is to opt-out of sharing your data for research and planning within the NHS. The different types of data opt outs are explained below.
For further information on how your data is used by NHS Digital please go to: NHS Digital Corporate Information
Type 1 Data Opt-Out
You can opt-out of data sharing if you do not want your confidential patient information held in your GP medical record to be used for purposes other than your individual care.
To do this complete the form below and email to [email protected]
Click here to download our Type 1 Opt-Out Form
Type 2 Data Opt-Out/ National Data Opt-Out
This cannot be done via your GP practice. The National Data Opt-out stops information being shared by NHS England and other NHS services which is not being shared for the purpose of direct patient care.
You can use the link below to visit the NHS Website and complete the National Data Opt-out form.
Choose if data from your health records is shared for research and planning – NHS (www.nhs.uk)
Please note: Patient identifiable/ sensitive data is never shared with outside services unless we have a legal right or obligation for doing so.
We are fully compliant with the Data Protection Act 2018 (and GDPR18).
Non-NHS(Private) Work-Fee Payable
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A guide for doctors to share with their patients explaining why they charge fees for certain requests.
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Practice Information Leaflet
Click here to view our Practice Information Leaflet