ACCESS TO MEDICAL RECORDS
Wolston Surgery is pleased to be able to work with our IT suppliers to provide patients with online access to their medical records. This is a new availability and we need to ensure that it does not disadvantage or put at risk our most vulnerable patients such as children, the elderly, those with mental health issues or those in abusive relationships. As such we have created a process that may appear to be overly bureaucratic but we hope you will support us in helping to protect these patients.
As yet there is no guidance on how to protect children and the systems are not sophisticated enough to turn on and off as the child ages so we have decided not to allow on-line access to patients under the age of eighteen years. At this age we will grant access at the request of the individual. We appreciate this may be frustrating for the vast majority of parents but we cannot see any other way to protect vulnerable children. This has been raised as an issue nationally but as yet no workable solution has been identified.
It is likely that some carers of individuals who lack appropriate capacity will wish to access the records of those for whom they care. The decision to allow access will be made on a case by case basis. The needs and desires of the individual patient will always be the overriding consideration.
Wolston Surgery started using computer systems to record medications and diagnosis in 1998. As the systems have changed there has been some data degradation and old codes have not always mapped successfully to new codes. This has also been a problem when records have transferred in from other practices. (An example of this was some men having the hysterectomy code added to their records.) As such, there may be some codes on your records that you do not recognise or are incorrect. We are very keen to improve the quality of our records so please advise us of anything in your records that you think is an error by writing to us or emailing – firstname.lastname@example.org. (Please be aware that although our email address is encrypted and secure, your system may not be so it may be safer to write.) If an error has been made we will do our best to rectify the record. If you disagree with something in your records that we cannot confirm is an error, we may be able to insert your comments.
The practice has the right to remove online access to services for anyone that doesn’t use them responsibly or if we have concerns you are being forced to share your records inappropriately.
It will be your responsibility to keep your login details and password safe and secure. If you know or suspect that your record has been accessed by someone that you have not agreed should see it, then you should change your password immediately. If you can’t do this for some reason, we recommend that you contact the practice so that they can remove online access until you are able to reset your password.
If you print out any information from your record, it is also your responsibility to keep this secure. If you are at all worried about keeping printed copies safe, we recommend that you do not make copies at all.
Important Things to Consider
Before you apply for online access to your record, there are some other things to consider. Although the chances of any of these things happening are very small, you will be asked that you have read and understood the following before you are given login details.
There may be something you have forgotten about in your record that you might find upsetting.
Abnormal results or bad news
Having access to test results or letters, you may see something that you find upsetting to you. This may occur before you have spoken to your doctor or while the surgery is closed and you cannot contact them.
Choosing to share your information with someone
It’s up to you whether or not you share your information with others – perhaps family members or carers. It’s your choice, but also your responsibility to keep the information safe and secure.
If you think you may be pressured into revealing details from your patient record to someone else against your will, it is best that you do not register for access at this time.
Your medical record is designed to be used by clinical professionals to ensure that you receive the best possible care. Some of the information within your medical record may be highly technical, written by specialists and not easily understood.
Information about someone else
If you spot something in the record that is not about you or notice any other errors, please log out of the system immediately and contact the practice as soon as possible.
What does that mean, I’ll Google it!
We are aware that your medical records will contain information you might not understand. Quite often, it is very tempting to Google medical words and phrases.
Whilst we would not encourage this but if you do Google please only use accredited peer-reviewed sites for accurate information. We recommended using www.patient.co.uk as this will have almost all of the information that you might need
What you can access
Below are the records you will be able to access. Please read through each record area so that you understand, signing up for access implies you agree to the terms and wish to access the all/certain areas of your records.
This is a record of your immunisations that are held electronically.
Medical allergies that have been recorded with a code will appear here. A number of patients have a record of a penicillin allergy that is inaccurate so please let us know if you think your record is inaccurate.
This is a record of major medical diagnosis. If something is missing or you do not agree, please do not use an appointment to let us know but follow the process outlined above If you write to us with any errors you believe exist and we will review your medical notes. We will then advise you of any changes we have made or if we need to discuss further.
It is important to realise that laboratory results may be outside of the so-called “normal range” for many reasons, such things as race, age, degree of physical activity, problems with collection and/or handling of the specimen and a large number of non-illness-related factors. The ‘normal range ‘ also only covers 95% of patients which mean that 5% of healthy patients fall outside of the normal range, even when there is nothing wrong with them.
It is important to realise it is not usually possible to diagnose a disease with a blood test alone. It may, however, help you to learn more about your body and detect potential problems in early stages when treatment or changes in personal habits can be most effective.
The comments your doctor attaches to your results are their interpretation of whether or not any changes are meaningful.
Normal, no action The result is within the normal range for the test and no further investigation or treatment is needed.
Acceptable The result is very close to the normal range for the test and not concerning or the result is acceptable for you. (see paragraph above)
Routine appointment This means the doctor wishes to explain the result(s) face to face as detailed explanations and/or further treatment or investigation(s) may be necessary.
Repeat in 1month/2month/3months etc. The result is currently acceptable but the doctor wishes to recheck this at a later date either to ensure that there are no further changes or as part of ongoing monitoring perhaps due to medication/ underlying illness.
Other comments not listed above are normally self-explanatory but if in doubt can be checked with office staff.
A list of the current medication you have on repeat or have had issued acutely recently.
You can see the coded entries in your electronic consultations from us and previous practices with compatible IT. These are records the clinical staff have made after your contacts with the surgery e.g. appointments, telephone consultations and visits.
If you believe something is factually wrong please let us know as above.
To access your medical records or to register for this facility please follow the guide below.
PLEASE NOTE: if you are already registered for on-line access (prior to consultations, test results, etc, being opened up) you will need to contact the Surgery (either via telephone or email email@example.com and ask for your account to be updated to allow full access.
Access to Medical Records