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Your Medical Information
You have a right to request a copy of your medical records held on file. Requests must be submitted in writing and will be fulfilled within 30 days of receipt. There may be occasions in exceptional circumstances where this may be extended.
Access to Medical Records
Under the Data Protection Act and Access to Health Records Act, patients can request to view their medical records and/or request that copies be sent to third parties acting on their behalf. To request a copy of records please complete the Patient Application for Access to Health Records form. For any request acting on others behalf please ensure written consent from the patient is provided. The form must be completed prior to the release of any records (charges may apply).
If the patient is aged over 16, information can only be released to the patient, unless the patient has authorised a designated third party individual to act on their behalf or have access to their medical records.
Sharing your GP medical record with other healthcare professionals involved in your care
In Wales, 64 groups of GP practices have been established and these are known as ‘Primary Care Clusters’. Their job is to ensure that the health and social care needs of all their patients are met, in the best possible way. Within each cluster, GPs will work alongside Nurse Practitioners, Pharmacists and other Allied Health Professionals, such as Physiotherapists, to share information and resources between them. Some of the benefits of this way of working are:
- Continuation of the existing patient-doctor relationship in the absence of your usual GP
- Improved access to consultations across different sites
- A wider range of services
Who will be able to access my medical record and what will they use it for?
A qualified healthcare professional will be able to access your GP medical record. This will usually be for the specific problem you representing with, and will allow the professional assessing you to have quicker, easier access to relevant information about you.
Cluster Pharmacists may access your record when, for example, undertaking prescription reviews or answering any queries about your medication. This is to ensure that medicines are prescribed safely, efficiently and effectively.
Other staff within the practice, such as receptionists, will also have access to your medical record to carry out tasks such as processing prescriptions, delivering test results and directing you to the most appropriate healthcare professional.
All healthcare professionals accessing your records will normally be employed by either one of the GP Practices within the cluster or by the Local Health Board.
What information can be accessed?
Information, which can be accessed, where there is a need includes:
- Personal information, such as name, date of birth, gender;
- Allergies;
- Medication;
- Hospital admission, attendances and referral dates;
- Vaccinations and immunisations;
- Test results, including measurements such as blood pressure;
- Diagnoses (current and post problems);
- Treatment and medical procedures.
What information will be blocked from viewing?
Any information containing details of a 3rd party will routinely be blocked from viewing . You may also ask for specific sensitive information to be hidden. For example, it may be possible to hide particularly sensitive information such as sexually transmitted diseases, termination of pregnancy, etc. from certain individuals. If you have any questions please discuss this initially with your Practice Manager.
How will my information be kept secure and confidential?
Your GP medical record is stored on a secure computer system and access to it is strictly controlled. All of the practices within the cluster, and the local Health Board, will have signed an agreement to confirm that they will follow the strict controls in place around the computer system itself, and around the staff who are allowed to access the system. Everyone working within the cluster has a legal, contractual and professional duty to keep information about you secure and confidential.
Can I find out who has viewed my medical record?
Every time your electronic GP medical record is accessed, an audit log is created. These audit logs are retained so if you are concerned that someone has inappropriately accessed your record, please discuss this initially with the Practice Manager.
Is there a danger someone else could hack into my record or that my information could be lost?
Contracts are in place with the supplier of the clinical computer systems to ensure that they have robust security measures installed. These measures will prevent any information from being accessed without permission, lost or accessed inappropriately by a third party.
For further information
If you would like additional information, you can discuss the sharing of your medical records with the Practice Manager, GP or any other member of the healthcare team.