Detailed Care Records
What information do you keep in Detailed Care Records?
We keep information that enables us to provide you with safe, effective care. The information we keep falls into two categories.
- Demographic information
This includes your name, address and contact details.
- Clinical information
This will include details of any medicines, allergies and health conditions. In time it will also include information about the treatment you have received during an appointment or visit.
How will this benefit me?
Moving to electronic Detailed Care Records will bring about a number of improvements:
- Health care staff will be able to get a more complete picture of your health care.
- Health care staff will have quicker access to your records so they can provide more effective care.
- Better sharing of information improves the efficiency of the health service.
Will you transfer all my paper records into electronic Detailed Care Records?
No. We will not transfer all of the information we hold on paper. We will only transfer information that is relevant to the care you might need in the future. This will be done gradually over the coming years and we will inform you as individual services in NHS Bury start to record clinical information electronically.
When will you start recording Detailed Care Records electronically?
At NHS Bury, we already hold demographic information about you electronically to enable us to book appointments for you, make referrals to our services and manage staff caseloads. Currently clinical information is held in paper documents that may be held in a patient’s home or in one of the Trust clinics or offices.
Our services will start to record clinical information electronically gradually over the coming years. You will be informed when a service caring for you starts to do this and be given the choice of whether you would like this information to be shared.
Which services are starting to record clinical information electronically?
In summer 2010, the Community Eye Service will start to record Glaucoma assessments electronically. This is a small pilot to test the process and we plan to roll this out to a small number of services later in the year. If your assessment is going to be recorded electronically you will receive information about your choices with your appointment letter.
If I am being treated by the Community Eye Service do I need to do anything?
If you are happy for your Glaucoma assessment to be recorded electronically, you do not need to do anything. If you have any concerns please contact our PALS team on 0800 328 3166.
When will you start to share information with other NHS organisations electronically?
The NHS Care Records Service is being rolled out to other NHS organisations gradually over the coming years. Currently NHS Bury is not able to share Detailed Care Records electronically with other organisations but will start to do so in the near future. Healthcare professionals working in other NHS organisations must be involved in your care to be able to access your record.
Limiting the sharing of your Detailed Care Record
- You can choose not to share your Detailed Care Records between NHS organisations. If you would like do this, please talk to a member of the PALS team on 0800 328 3166.
- If you decide not to have a Detailed Care Record this will not affect your Summary Care Record and vice versa.
Other ways to limit who sees your health information
You may be happy with the idea of sharing information, but could have concerns about certain aspects being seen by all clinical staff involved in your care. For example, this may be information about a condition you may not want people to know about.
In this situation, you may be able to ask that this information is ‘sealed’ (sometimes known as creating a ‘sealed envelope’). If we seal information, it restricts the amount of information health-care staff can see without first asking for your permission. However, this can be ignored in exceptional circumstances, for example, if this is not in the public interest to do so.
If anyone tries to see the sealed information, it will trigger an alert to our Privacy Officer who may investigate the matter.
It is not yet possible to seal information on the IT system that NHS Bury use, however we hope to make this facility available later this year. Until it is possible to seal information, patients being treated by services recording clinical information electronically (currently just the Community Eye Service) can ask for this information to be recorded on paper and register their wish to seal the information when this facility is available.
How will you control access to my care records?
We will use the strongest national and international security measures available for keeping your information safe and secure. Any member of staff looking at your care records:
- Must be involved in your care.
- Must have an NHS Smartcard, with a chip and pass code (like a bank card and PIN).
- Should only see the information they need to see to do their job.
- Will have their details recorded – who they are and if they have added or changed any of your information.
All staff who are able to see patient information have a professional, ethical and legal responsibility to keep your details secure and confidential.
Respecting your confidentiality
By law, everyone working for or on behalf of the NHS must respect your confidentiality and keep all information about you secure. In every place where you’re treated by the NHS, there are people responsible for protecting your confidentiality. These people are often known as ‘Caldicott Guardians’ and can be contacted via the PALS team.
The NHS published the NHS Care Record Guarantee for England. This says how we will collect, store and access your electronic records, and sets out your options to take part in the service.
More information
For more information about the NHS Care Records Service, please visit www.nhscarerecords.nhs.uk
For local information you can contact our PALS team on 0800 328 3166. The service is available during normal office hours. At other times you may leave a message and the team will call you back, or you can send an email at any time to bur-pct.enquiries@nhs.net
If you have a general question about the NHS Care Records Service you can phone the NHS Care Records Service Information Line on 0845 603 8510.