THE WELLBRIDGE PRACTICE

Sharing your medical information

Background

For a number of years, work has been ongoing to improve the way that medical records are made available to treating clinicians. As a result of this work we are now able to share clinical information between certain health professionals.

This means that with your consent, we are able share your medical records with those in the NHS who are involved in your care. NHS staff can only access shared information if they are involved in your care and being an electronic service an audit log is maintained showing when and who has accessed medical records.

This helps clinicians to make decisions based upon a wider knowledge of you and also helps to reduce the number of times that you or your family members are asked the same question. In short it assists clinicians to provide more ‘joined up care’.

We already share records of children for child protection reasons and patients who are under the care of the District Nursing Team.

If I agreed, who could see my records?

Clinicians treating you, who have access to the same system can view and in some cases update your medical records. Locally this includes the Walk-In-Centre, many departments at local hospitals (including A&E) and community services, such as the District Nursing Team. It is anticipated that over time more health services will be able use this system to access records if appropriate.

Clinicians outside of the surgery who wish to access your medical records will ask for your permission to do so and will need to have been issued with a NHS Smartcard. This is a ’chip and pin’ card -similar to a bank card.

 Can I choose who sees my record?

Yes you can—there are two levels of consent. The first is to agree to sharing your medical records OUT of the practice. This is your agreement that records maintained by your GP can be seen, subject to your authority at the time, by clinicians working outside of the surgery. The second is agreeing to share your records IN. This means that your GP can see the records made by other health professionals who have access to EDSM.

However, as the treating clinician needs to ask your permission to see the records at the beginning of each period of care you are in control of who can see your medical information.

 What can I do if I don’t want to allow access to my records?

 As we feel this access will enhance patient care we will automatically ‘opt you in’ to both parts of the scheme.

If you prefer not to be then please mention it to a member of the reception team.

You are free to change your mind at any time.

I can see the benefits of the other people treating me seeing my notes, but what if there is a matter that I want to stay just between me and my doctor?

You can ask for any consultation to be marked as private, this means that viewing is restricted to the surgery, but allows the rest of the record to be viewed by whoever else is treating you. It is your responsibility to ask for a consultation to be marked as private.

How is this different from previous arrangements?

In the past other NHS Services to see your current medications and the drugs that you are allergic or sensitive to via a Summary Care Record.

This new system allows your full record to be seen. (is this correct?)

Can I change my mind?

Yes, you can always change your mind and amend who you consent to see your records. For instance you can decline to share your records out from the surgery, but if you built up a relationship with the physiotherapist who was treating you and they asked you if they could look at an x-ray report, you could give your consent at that point for them to view your records.

You will be referred back to us to change your preference, so the physiotherapist treating you should—with your permission—be able to see your records by the time of your next appointment.

If I decline—what happens in an emergency?

In the event of a medical emergency, for instance if you were taken unconscious to A+E, and the clinician treating you feels it is important to be able to see your medical records he is able to override any consents set.

However, the doctor has to give a written reason for doing so. Where this happens an audit is undertaken by the local Caldicott Guardian (the person with overall responsibility for Data Protection compliance).

Can anyone else see my medical records?

Not unless you give your written consent for this to happen.

On a daily basis, we get requests from Insurance Companies to either have copies of medical records or excerpts from patients’ medical records. This requires your signed consent as it has not been requested to treat/care for you.

Occasionally we are asked for information from the medical records for legal reasons, again this has to be done with your written consent, or in very exceptional circumstances, by court order.

Any questions?

If you have any questions, please speak to reception.

If necessary the receptionist will arrange for another member of the team to give you a call.

Suggestions & Complaints

We don't always get it right but we always try to do our very best for patients. If you would like to let us know how we can improve our service to our patients please let us know.   We have a Suggestion Box situated in our waiting area.  Please be aware that we will not acknowledge any suggestions left in this box.

Comments, complaints and problems

If you have any comments, complaints or suggestions either about your medical treatment or about our practice in general, please contact your doctor who will do his/her best to help.

If you prefer you can speak to the Practice Manager, Mrs Keeley Bruce.

Please see the leaflet If things go wrongwhich explains the complaints procedure in detail.

THE WELLBRIDGE PRACTICE

OUR PRACTICE CHARTER

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THE WELLBRIDGE PRACTICE - CHAPERONE POLICY

Definition of a Chaperone: A person who accompanies and looks after another person or group of people.

This policy is designed to protect both patients and staff from abuse or allegations of abuse and to assist patients to make an informed choice about their examinations and consultations.

GUIDELINES

The doctor must be satisfied that the chaperone will: 

1. be sensitive and respect the patient’s dignity and confidentiality 
2. reassure the patient if they show signs of distress or discomfort 
3. be familiar with the procedures involved in a routine intimate examination 
4. stay for the whole examination and be able to see what the doctor is doing, if practical 
5. be prepared to raise concerns if they are concerned about the doctor’s behaviour or actions.

Clinicians (male and female) should consider whether an intimate or personal examination of the patient (either male or female) is justified, or whether the nature of the consultation poses a risk of misunderstanding.

• The clinician should give the patient and the chaperone a clear explanation of what the examination will involve.
•  
• The chaperone will always adopt a professional and considerate manner - be careful with humour as a way of relaxing a nervous situation as it can easily be misinterpreted.
•  
• Always ensure that the patient is provided with adequate privacy to undress and dress.
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• Ensure that a suitable sign is clearly on display in each consulting or treatment room offering the chaperone service if required.To remove any misunderstanding and either clinician or patient feeling uncomfortable it is normal policy to use or consider using a chaperone. Patients will always be offered the services of a chaperone for any intimate examination.Patients who request a chaperone should never be examined without a chaperone being present. If necessary, where a chaperone is not available, the consultation / examination should be rearranged for a mutually convenient time when a chaperone can be present.

WHO CAN ACT AS A CHAPERONE?

A variety of people can act as a chaperone in the practice, both clinical and non-clinical.

Where the practice determines that non-clinical staff will act in this capacity the patient must agree to the presence of a non-clinician in the examination, and be at ease with this. If the patient is not happy to have a non clinician present, and there are no nurses available, an alternative appointment should be made when a nurse or HCA can be available.

The staff member should be comfortable in acting in the role of chaperone, and be confident in the scope and extent of their role. Members of staff undertaking this role will have received training/instruction on the role of a chaperone. 

All staff eligible to chaperone have been DBS checked.

CONFIDENTIALITY

• The chaperone should only be present for the examination itself, and most discussion with the patient should take place while the chaperone is not present.

• Patients should be reassured that all practice staff understand their responsibility not to divulge confidential information.

Click here to link to the latest GMC guidelines for intimate examinations: http://www.gmc-uk.org/guidance/current/library/maintaining_boundaries.asp#10

PROCEDURE

• The clinician will ask the patient if they would like a chaperone as appropriate and record the offer in the patient’s record using code XaEiq Chaperone offered.

• If the patient declines the offer this should be recorded in the patient’s record using the code XaEis Chaperone refused.

Where no chaperone is available the examination will not take place if a chaperone has been identified as being necessary. The patient should not normally be permitted to dispense with the chaperone once a desire to have one present has been expressed.

• The chaperone will enter the room discreetly and remain in room until the clinician has finished the examination.
• The chaperone will always attend inside the curtain at the head of the examination couch and watch the procedure.
• To prevent embarrassment, the chaperone should not enter into conversation with the patient or GP unless requested to do so, or make any mention of the consultation afterwards.
• Following the examination the chaperone will remain in the room, outside the curtain, until the patient has dressed.
• Following the examination the chaperone will make a record in the patient’s notes by entering the code XaEir Chaperone present followed by text for example: examination by RM. JB present. No concerns.The record should state the name of the doctor carrying out the procedure and the initials of the chaperone. The record should confirm that there were no problems, or give clear details of any concerns or incidents that occurred.

• The patient can refuse a chaperone, and if so this must be recorded in the patient’s medical record. Concerns:   If a chaperone has concerns following an examination these should be made known to the Practice Manager immediately. In the absence of the Practice Manager a detailed report outlining concerns should be written immediately after the consultation and discussed with the Practice Manager or Senior Partner as soon as possible. 

Reviewed on: 30.9.19 by Practice Manager

We operate an Equality and Diversity Policy as follows: 

The term ‘visitor’ used below refers to anyone (including patients and their family members, other visitors and contractors) making use of the Practice’s premises and services.

The Practice:

• will ensure that all visitors are treated with dignity and respect
• will promote equality of opportunity between men and women 
•  will not tolerate any discrimination against, or harassment of, any visitor for reason of age, sex, marital status, pregnancy, race, ethnicity, disability, sexual orientation, religion or belief
• will provide the same treatment and services (including the ability to register with the Practice) to any visitor irrespective of age, sex, marital status, pregnancy, race, ethnicity, disability, sexual orientation, religion or belief

Applicability

This Policy applies to the general public, including all patients and their families, visitors and contractors.

Procedure

Discrimination by the Practice against you.
If you feel discriminated against:

• You should bring the matter to the attention of the Practice Manager.
• The Practice Manager will investigate the matter thoroughly and confidentially within 5 working days.
• The Practice Manager will establish the facts, and decide whether discrimination has taken place  and advise you of the outcome of the investigation within 10 working days. 

If you are not satisfied with the outcome, you should raise a formal complaint through the Practice’s Complaints Procedure (please ask for a copy of our leaflet “If things go wrong” from reception. 

Discrimination against the Practice’s staff
The Practice will not tolerate any form of discrimination or harassment of our staff by any visitor. Any visitor who expresses any form of discrimination against, or harassment of, any member of our staff, will be required to leave the Practice’s premises forthwith. If the visitor is a patient, he/she may be removed from the Practice’s list if any such behaviour occurs on more than one occasion. 

In addition to the above provision Dorset PCT provide PALS (Patient Advice & Liaison Service) 

What is PALS?

PALS is an accessible and confidential service for patients, relatives and carers. PALS acts independently when handling patient and family concerns, liaising with staff, managers and, where appropriate, relevant organisations to negotiate immediate or prompt solutions. If necessary we can refer patients and families to specific local or national-based support agencies.

PALS aims to:

• offer advice and support to patients
• provide information on NHS services
• listen and respond to queries
• help sort out problems on your behalf

Who do I contact?

PALS Officer,
Dorset PCT, 
Poundbury Road,
Dorchester. 
DT1 2PN.
Telephone: 01305 361285 :
Send an email: PALS@dorset-pct.nhs.uk

THE EQUALITY DUTY.

In the exercise of the functions of the Practice we will have due regard to the need to:

• Eliminate unlawful discrimination, harassment and victimisation and other conduct prohibited by the Act.

• Advance equality of opportunity between people who share a protected characteristic and those who do not.

• Foster good relations between people who share a protected characteristic and those who do not.

• This involves:

• Removing or minimising disadvantages suffered by people due to their protected characteristics.

• Taking steps to meet the needs of people from protected groups where these are different from the needs of other people.

• Encouraging people from protected groups to participate in public life or in other activities where their participation is disproportionately low.The equality duty covers the nine protected characteristics: age, disability, gender reassignment, pregnancy and maternity, race, religion or belief, sex and sexual orientation.   The Practice will also have due regard to the need to eliminate unlawful discrimination against someone because of their marriage or civil partnership status.

• We will take account of disabled people's disabilities.   We will endeavour to foster good relations, tackle prejudice and promote understanding between people from different groups.   Complying with the duty may involve treating some people more favourably than others.