About Health Records
Health records play an important role in modern healthcare. They have two main functions, which are described as either primary or secondary.
Primary Function of Health Records
The primary function of healthcare records is to record important clinical information, which may need to be accessed by the healthcare professionals involved in your care. Information contained in health records includes:
- The treatments you have received,
- Whether you have any allergies,
- Whether you’re currently taking medication,
- Whether you have previously had any adverse reactions to certain medications,
- Whether you have any chronic (long-lasting) health conditions, such as diabetes or asthma,
- The results of any health tests you have had, such as blood pressure tests,
- Any lifestyle information that may be clinically relevant, such as whether you smoke, and
- Personal information, such as your age and address.
Secondary Function of Health Records
Health records can be used to improve public health and the services provided by the NHS, such as treatments for cancer or diabetes. Health records can also be used:
- To determine how well a particular hospital or specialist unit is performing,
- To track the spread of, or risk factors for, a particular disease (epidemiology), and
- In clinical research, to determine whether certain treatments are more effective than others.
When health records are used in this way, your personal details are not given to the people who are carrying out the research. Only the relevant clinical data is given, for example, the number of people who were admitted to hospital every year due to a heart attack.
Your data may also be used to determine your risk factor for future health issues, hospital admissions or care needs. If we use your data in this way you can be reassured that it will be anonymised.
Types of Health Record
Health records take many forms and can be on paper or electronic. Different types of health record include:
- Consultation notes, which your GP takes during an appointment,
- Hospital admission records, including the reason you were admitted to the hospital,
- The treatment you will receive and any other relevant clinical and personal information,
- Hospital discharge records, which will include the results of treatment and whether any follow-up appointments or care are required,
- Test results,
- Photographs, and
- Image slides, such as those produced by a magnetic resonance imaging (MRI) or computerised tomography (CT) scanner.
There are strict laws and regulations to ensure that your health records are kept confidential and can only be accessed by health professionals directly involved in your care.
There are a number of different laws that relate to health records. The two most important laws are:
- Data Protection Act (1998), and
- Human Rights Act (1998).
Under the terms of the Data Protection Act (1998), organisations such as the NHS must ensure that any personal information it gathers in the course of its work is:
- Only used for the stated purpose of gathering the information (which in this case would be to ensure that you receive a good standard of healthcare), and
- Kept secure.
It is a criminal offense to breach the Data Protection Act (1998) and doing so can result in imprisonment.
The Human Rights Act (1998) also states that everyone has the right to have their private life respected. This includes the right to keep your health records confidential.
The NHS is currently making some important changes to how it will store and use health records over the next few years. See the Service description section for more information.
For more information please follow the links below.
Care.data – modern data service for the NHS
How We Use Your Health Records
Why we collect information about you?
In the National Health Service, we aim to provide you with the highest quality of health care. To do this we must keep records about you, your health, and the care we have provided or plan to provide to you.
These records may include:
- Basic details about you, such as an address, date of birth, next of kin.
- Contact we have had with you such as clinical visits.
- Notes and reports about your health.
- Details and records about your treatment and care.
- Results of x-rays, laboratory tests, etc.
- Relevant information for people who care for you and know you well, such as health professionals and relatives.
It is good practice for people in the NHS who provide care to:
- Discuss and agree with you what they are going to record about you,
- Give you a copy of letters they are writing about you; and,
- Show you what they have recorded about you if you ask.
How Your Records are Used
The people who care for you use your records to:
- Provide a good basis for all health decisions made by you and care professionals.
- Allow you to work with those providing care.
- Make sure your care if safe and effective and;
- Work effectively with others providing you with care.
Others may also need to use records that are about you to:
- Check the quality of care (such as clinical audit).
- Protect the health of the general public.
- Keep track of NHS spending.
- Manage the health service.
- Help investigate any concerns or complaints you or your family have about your health care.
- Teach health workers and,
- Help with research.
Some information will be held centrally to be used for statistical purposes. In these instances, we take strict measures to ensure that individual patients cannot be identified.
We use anonymous information, wherever possible, but on occasions, we may use personally identifiable information for essential NHS purposes such as research and auditing. However, this information will only be used with your consent, unless the law requires us to pass on this information.
You Have the Right
You have the right to confidentiality under the Data Protection Act 1198 (DPA), the Human Rights Act 1998, and the common law duty of confidence (the Disability Discrimination and the Race Relations Acts may also apply).
You have a right to ask for a copy of your records about you.
- Your request must be made in writing to the organisation holding the information.
- There may be a charge to have a printed copy of the information held about you.
- We are required to respond to you in 1 month.
- You will need to give adequate information (for example full name, address, date of birth, NHS number, etc.)
If you think anything is inaccurate or incorrect, please inform the organisation holding your information.
The Data Protection Act 1998 requires organisations to notify the Information Commissioner of the purposes for which they process personal information.
The details are publically available from the Information Commissioner:
Tel: 01625 545745
How we Keep Your Records Confidential
Everyone working for the NHS has a legal duty to keep information about you confidential
We have a duty to
- Maintain full and accurate records of the care we provide you.
- Keep records about you confidential, secure, and accurate.
- Provide information in a format that is accessible to you (i.e., in large type if you are partially sighted).
We will not share information that identifies you for any reason, unless:
- You ask us to do so;
- We ask and you give us specific permission;
- We have to do this by law;
- We have special permission for health research purposes or
- We have special permission because the interests of the public are thought to be of greater importance than your confidentiality.
Our guiding principle is that we are holding your records in Strict Confidence.
Who are our Partner Organisations?
We may share information with the following main partner organisations:
- Commissioning Support Units.
- NHS Trusts (Hospitals, CCG’s).
- Special Health Authorities.
- Ambulance Service.
We may share your information, with your consent and subject to strict sharing protocols about how it will be used,
- Social Services.
- Education Services.
- Local Authorities.
- Voluntary Sector Providers.
Anyone who receives information from us also has a legal duty to:
Keep it Confidential.