Our Responsibilities Under The Data Protection Act 1998 and How You Can Access Your Health Records

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1 Information for Patients on Our Responsibilities Under The Data Protection Act 1998 and How You Can Access Your Health Records Contact numbers: Data Protection Officer Access to Health Records Team

2 The Data Protection Act 1998 T he Data Protection Act 1998 came into force on 1 March 2000 and applies to The Ipswich Hospital NHS Trust because it holds information about living people. The Act sets out guidelines that must be followed to ensure that personal information is kept safe and secure. To comply with the Act the hospital must tell you: who we are why we need your personal details to whom this information is, or might be, passed The Ipswich Hospital NHS Trust is registered with the Office of the Information Commissioner to hold personal details about our patients. Why we need your personal details The primary reason for holding your personal details is to give you the healthcare you need. We use these details to: identify you correctly when providing your care and treatment; and enable us to contact you about your appointments or admission to hospital. The Ipswich Hospital NHS Trust cares for thousands of patients. Every patient has his or her own medical record casenote file with a unique number. This record contains your personal details: name, address, date of birth, GP name, next of kin and other relevant details. It also contains your medical history any treatment, test results or care that has been provided to Page 1

3 you during any stay or appointment at this hospital. Much of this information is also held on the hospital computer system. Only staff directly involved with your care (including administrative staff) are allowed to access your medical record this is called the Need to Know Principle. This information is also needed for other reasons: For clinical audit Consultants regularly review their patients notes to ensure that the treatments used are beneficial to the patients. For medical research Most information used for research is provided without patients names and addresses or any other way of identifying individuals. Occasionally some staff need to look at particular casenotes for research purposes. However they are not allowed to identify individuals in any reports produced as a result of the work. For patient surveys It is important that we learn about patients experiences and their opinions of the services that they have received. In this way we can use these views, opinions and comments to improve what we do and how we do it. Patient surveys may be undertaken by hospital staff reviewing the service that they provide or by the Trust or the Government. You may be asked to complete a survey form, be interviewed by a researcher or invited to join a focus group. Taking part is entirely up to you and if you choose not to, your care and treatment will not be affected in any way. Most surveys are anonymous and all information given will be treated in the strictest confidence. For the prevention and control of disease Public Health Health Authorities monitor the level of illness or disease within the local community. This is to make sure that hospitals provide the right services to their patients and can also try to prevent disease outbreaks from spreading. To receive payment from the Government for treating you The hospital is funded on the number of patients treated and the type of treatments provided. We must provide certain information to your Primary Care Trust and the Government to get the money we need to provide the service. Usually this does not contain your name or address but has coded information about your hospital visit. When you provide information to the hospital it is assumed that you are consenting to the information being used for all these purposes. If you feel strongly that you do not want your information used for some of these reasons then it can be marked on your file and we will respect your wishes where possible. Where does the information contained in your hospital record come from? The personal details contained in the medical record may come from various sources: yourself or family / guardian, your GP / dentist or a doctor at another hospital as well as the records created at the hospital. Occasionally the hospital obtains more up-to-date details about a patient from other NHS organisations, particularly if he or she has moved house or changed GP and not told the hospital. Page 2

4 To whom are we allowed to pass information? Hospital staff provide a service to relatives and friends by providing information about which ward the patient is on or whether they are able to visit. Although most patients are happy to receive visitors or telephone calls, please let the ward staff know if you would prefer not to be contacted or visited whilst in hospital. For more information Any questions about your data and the way the hospital uses it should be directed to the Data Protection Officer on Alternatively, you may ask a member of staff to put you in touch with a member of the Patient Advice and Liaison Service (PALS) or telephone Freephone The hospital employs Chaplaincy staff but under the Need to Know Principle we will only pass your religious beliefs on to them with your consent. If you would like to be visited by a member of the Chaplaincy team during your stay, please let the nursing staff know. The hospital may send information about you to other people who are involved in your care. Consultants at other hospitals, your GP/dentist or Social Care Services may receive personal details about you if they need to be involved in your care after you leave this hospital or to help with discharge arrangements. The Department of Works and Pensions (formerly the Benefits Agency) often requires us to supply information about your hospital stay as it may affect any pension or benefits you receive. We have to provide information to the local primary care organisations about your stay or appointment. We also pass the same information to the Department of Health. This does not usually contain your name and address but does include your NHS number. Page 3

5 Viewing Your Own Medical Records Y ou have the right to view your own medical records. Many people are unsure about what this means. This guide will explain what you can expect. If you would like to be provided with a copy of your records, you should fill out the application form in this guide and send it to: Access to Health Records Team Information Governance Department (N031) The Ipswich Hospital NHS Trust Heath Road Ipswich IP4 5PD Who has the right to apply? The patient Any person authorised in writing to apply on behalf of the patient. Any person having parental responsibility for a child under the age of 16. Any person appointed by the Courts to manage the affairs of the patient. (Documented proof must be given.) Where a patient has died, the patient s personal representative. (Documented proof needs to be supplied.) Which records can I see? The records referred to in this guide are written and computerised medical records. Apart from the few exceptions listed below, we are obliged to let you see your records and also to explain any part of the record which you do not understand. Page 4

6 When can records be kept from me? When we believe that access is likely to cause you or another person serious physical or mental harm. When the record would disclose that an individual had been born of the consequence of treatment services within the meaning of the Human Fertilisation and Embryology Act When the record contains information the patient expressly stated must not be revealed. When the record relates to, or has been given by, anyone except a doctor or health professional involved in the patient s care, unless their consent has been given. When we think a patient, under the age of 16, cannot understand what the application to see his or her record means. Do I have to pay? There may be a charge in certain circumstances, for this service. After your application has been received, you will be advised of any likely costs before dealing with your request. What happens after I apply? When the application form is received by the Access to Health Records Team, a strict process is undertaken. You should receive a response from us within 40 days of receiving your application. Once we have the permission from the consultant we will send you a photocopy of your records. If you wish to view your original records please contact the consultant in charge of your care. What if I disagree with what is written? If you believe any facts in your records are wrong, you can ask us to change them. We must either make the correction or note your disagreement (and any discussion about it) in the records. We must give you a copy of the correction and any notes made. (You cannot remove anything from the records or amend them yourself.) If you think your right to access has been unfairly denied, you can appeal. This is usually done through our PALS team or the Trust s complaints procedure. You can ask the Independent Complaints Advocacy Service for advice about how to complain. Their telephone number is For more information For further information or advice, please contact the Access to Health Records Team on Alternatively, you may ask a member of staff to put you in touch with a member of the Patient Advice and Liaison Service (PALS) or telephone Freephone Checks will be made to ensure the person applying has the right to apply particularly if applying on behalf of someone else. The records will then be located. We may then write to the most appropriate health professional (usually the consultant in charge of your care) for permission for the records to be released. Page 5

7 Application for Access to Medical Records (Data Protection Act 1998, Access to Medical Records Act 1990) Details of Patient Surname Forename(s) Address Date of birth Treatment Hospital number Approx date Details of Applicant (if different from above) Surname Forename(s) Address Relationship (please tick one box) I am the patient. I have been asked by the patient and attach his/her written consent. I am acting in loco parentis and the patient is under the age of 16. I am the personal representative of the deceased patient and attach confirmation of my appointment. (Documentary evidence is required eg Grant of Probate or letter from the solicitor stating that you are the executor.) I am appointed by the Courts to manage the affairs of the patient. (Documentary evidence is required eg proof of Power of Attorney.) Declaration I declare that the information, given by me, is correct to the best of my knowledge and that I am entitled to apply for the medical record referred to above, under the terms of the Data Protection Act 1998 and/or Access to Medical Records Act You are advised that making false or misleading statements in order to obtain access to personal information to which you are not entitled is a criminal offence. Signed: Date: Access to Health Records Team Tel: Fax: information.access@ipswichhospital.nhs.uk

8 Produced by: Information Directorate The Ipswich Hospital NHS Trust Heath Road, Ipswich, Suffolk IP4 5PD Direct line: Hospital switchboard: Published: March The Ipswich Hospital NHS Trust DMI ref: indd(RP)