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Confidentiality & Medical Records

Confidentiality & Medical Records

Locked blue folderThe practice complies with data protection and access to medical records legislation. Identifiable information about you will be shared with others in the following circumstances:

  • To provide further medical treatment for you e.g. from district nurses and hospital services.
  • To help you get other services e.g. from the social work department. This requires your consent.
  • When we have a duty to others e.g. in child protection cases anonymised patient information will also be used at local and national level to help the Health Board and Government plan services e.g. for diabetic care.

If you do not wish anonymous information about you to be used in such a way, please let us know.

Reception and administration staff require access to your medical records in order to do their jobs. These members of staff are bound by the same rules of confidentiality as the medical staff.

Freedom of Information

Information about the General Practioners and the practice required for disclosure under this act can be made available to the public. All requests for such information should be made to the practice manager.

Access to Records

In accordance with the Data Protection Act 1998 and Access to Health Records Act, patients may request to see their medical records. Such requests should be made through the practice manager and may be subject to an administration charge. No information will be released without the patient consent unless we are legally obliged to do so.

Consent

Where possible, a clinician must be satisfied that you understand and consent to any proposed treatment, immunisation or investigation. This can be in any of the following ways;

Implied Consent

Implied consent will be assumed for many routine physical contacts.

An explanation will be given to you about what he or she is about to do, and why.

The explanation should be sufficient for you to understand.

Expressed Consent

Expressed consent (written or verbal) will be obtained for any procedure which carries a risk that you may consider as being substantial. A note will be made in your medical record detailing the discussion about the consent and the risks.

Obtaining Consent

Consent will include the provision of all information relevant to your treatment.

Any questions you have will be answered honestly, and you will be given any information necessary to make an informed decision.

The person obtaining consent will be fully qualified and will be knowledgeable about the procedure and the associated risks.

The Practice acknowledges your right to refuse consent, delay the consent, seek further information, limit the consent, or ask for a chaperone.

Consent for children

Everyone aged 16 or more is presumed to be competent to give consent for themselves, unless the opposite is demonstrated. If a child under the age of 16 has “sufficient understanding and intelligence to enable him or her to understand fully what is proposed” (known as Gillick Competence), then he or she will be competent to give consent for him/herself. Young people aged 16 and 17, and legally ‘competent’ younger children, may therefore sign a Consent Form for themselves, but may like a parent to countersign as well.

For children under 16 (except for those who have Gillick Competence as noted above), someone with parental responsibility should give consent on the child’s behalf by signing accordingly on the Consent Form.



 
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