Information Governance (IG) is about how we look after your information. It ensures necessary safeguards for, and appropriate use of, patient and other personal information to ensure that we handle it carefully and confidentially.
Your right to confidentiality and privacy
Staff and volunteers across all of our services are required to comply with the requirements of GDPR16 and DPA18 and the NHS Confidentiality Code of Practice. To help with this, we have appointed a Caldicott Guardian. A Caldicott Guardian is a senior person responsible for protecting the confidentiality of patient and other service user information, and enabling appropriate information sharing.
Our HCRG Caldicott Guardian is our Medical Safety Officer. He is supported by the ‘Caldicott Function’ which is comprised of the IG Team and deputy Caldicott Guardians based out in our services. The Caldicott Function has responsibility to champion patient confidentiality and support staff in making decisions about how your information is handled.
We have a legal and ethical duty to keep your health records confidential. However, very occasionally we are required by law to pass on certain information about you. For example, this could be in the event of certain infectious diseases, in response to a court order or to help the police investigate a very serious crime. We will also share information with other agencies where there is danger of harm to a child or a vulnerable adult.
Your health records
Health records (or medical records) are a record of the health care you have received.
They hold general information (for example your name, address and next of kin) and information and reports about your health, including details of your illnesses, tests, prescriptions and other treatments.
Your doctor or nurse and team of health professionals caring for you keep records about your health and any treatment and care you receive from HCRG. The records may also include information from other NHS organisations involved in your care.
These records help to ensure that you receive the best possible care. They may be written down or held on a computer.
Our staff are responsible for the accuracy and safekeeping of your health records and you can help us to keep them accurate by informing us of any changes in your circumstances.
How is my information used?
The information in your health record is used primarily to treat you. We will only share your information with other health and social care professionals if in your best interests, and if for health and social care reasons.
What else could my information be used for?
Health records are also sometimes used to improve the care provided by HCRG and the NHS.
They can also be used:
- To determine how well a particular service is performing
- To track the spread of, or risk factors for, a particular disease
- In clinical research, to determine whether certain treatments are more effective than others
When health records are used in this way, your personal information is not given to the people who are carrying out the research; only anonymised data is used.
There may be some occasions that require the use of identifiable data and if we want to use your information in this way we will always ask for your consent first. This is generally for research or teaching purposes. You always have a right to say no.
How can I access my records?
You are allowed, by law, to access your written or computerised medical records. We will require your request in writing and we may ask you for proof of identity. If you would like further information or a copy of your records you can:
- Request your records online by clicking here
- Speak to the clinician who is caring for you
- Speak to the receptionist at the service providing your care
- Write to:
Progressive House, The Heath Business Park
Cheshire, WA7 4XJ
Can I have access to records about other people?
You can only have access to records relating to other people if:
- They have provided written authorisation
- You have parental responsibility for children under 16
- You have been appointed by a court and this is authorised in writing
- You are a representative of a deceased patient
Will I see all of the information in my records?
A healthcare professional is required to examine your records before they are released to you and if they believe that certain information in the health record might cause serious harm to your physical or mental health or to that of another person, or is classified as third part information, they may withhold that piece of information.
What if the information in my records is incorrect?
If after you have seen your medical records you think something is incorrect, you should discuss it with the person in charge of your care. If the incorrect information is non-clinical, such as a wrongly recorded name or address, this will be corrected.
If the information you think is incorrect is a health professional’s opinion, the information will not be amended but a comment may be added alongside the information to say that you disagree.
Usually, clinical information can’t be removed from your records unless a court orders it. This is because clinical staff need your full record to fully understand earlier decisions that were made about your care and treatment.
What if I’m not happy?
If you are not happy about the way your information is handled, you have the right to lodge a complaint with a supervisory authority. In the UK, this is the Information Commissioners Office (ICO) https://ico.org.uk/global/contact-us/.