Online Access
Patient information guides for online access:
Medical records are a record made of a consultation or activity related to patient care. They are a reference for the health care team and may include abbreviations and terms in medical language not used commonly in day to day discussion.
The record is intended for sharing information between those providing your care to provide continuity of care. It is entered as accurately recalled by the clinician and in a timely fashion during and /or shortly after your consultation
The main purpose of any clinical record is to provide continuity of care, but medical records are also used for other purposes: • Administrative and managerial decision-making within the NHS • Meeting current legal requirements, including enabling patients to access their records • Assisting in clinical audit • Supporting improvements in clinical effectiveness through research. •
Unlike hospital letters these notes are made during and/or just after you have spoken to a clinician or have been seen face to face. They may contain short hand with abbreviations. They may contains typos.
The following link may be useful for some commonly used abbreviations:
https://www.nhs.uk/nhs-app/nhs-app-help-and-support/health-records-in-the-nhs-app/abbreviations-commonly-found-in-medical-records/
Unfortunately, we do not have any additional time outside your (on average) 10 minute appointment slot to review these, to aid clarity in your reading them. They are a record for the practice.
Unless you feel there is an urgent need to add further information that may change how your concern/condition is managed, we do not have the capacity to provide appointments to ‘interpret’ our records for your further understanding.
If you feel there is a factual error, please contact our administration team directly or via E Consult and we may add the further information to your record.
Information will NOT be removed from your notes (unless proven to be incorrect personal information ) as this is a record of the professionals’ recollection of events.
Please be advised we have NO extra team members and NO extra appointments to deal with any queries. The time required for this work will come directly out of our capacity to provide appointments when we are already facing unprecedented pressures in primary care, with further increasing demand for appointments and a dwindling primary care work force, with no additional funding.
Clinical activity in your notes may be coded as ‘admin’ and this may appear on your record as a clinical entry, looking like an ‘appointment’. This is not to be confused with appointments you have had, or have, booked. This may be if your notes have been accessed to review notes/results/plan.
This is not, and was not, a ‘virtual appointment’ but a way of tracking work and providing an audit trail
From 1/11/22 individuals aged 16 and above MAY be able access their prospective medical records.
Currently, in accordance with BMA and RCGP advice, this is not a facility we feel we are able to offer safely. The workload and workforce crisis facing General Practice has severely limited our ability to undertake this additional programme of work without potential detriment to patient care. We have been working with guidance to provide this access but currently feel unable to offer this general access without the potential risk to patient safety and further limiting access to clinical staff for your health care needs. We are currently awaiting further advice from NHS England.
If you do wish to access your prospective records, please contact the patient reception team and your records will be reviewed within 1 working month to assess ongoing future access.
https://www.rcgp.org.uk/News/RCGP-statement-patients-access
TEST RESULTS:
Tests results: Minor test result abnormalities in well people may have no clinical relevance. By definition 5% of healthy people will have test results that fall just outside the 95% ‘normal’ reference interval.
All results will be taken in context of the patient history, previous results and trends.
The results of a tests will be viewed in a timely manner once received in the practice.
This may be by the duty GP if the requesting clinician is not available that day who will oversee if immediate action is required.
Unless needing urgent action, they will be left for the attention of that requesting clinician to ‘action’ on their next working day.
Please do not ask for more urgent review and comment on results unless there has been a deterioration in your health as this will mean the duty GP is not able to focus on other aspects of their role providing care.
The following website may be useful in considering your test results.
https://labtestsonline.org.uk/
Additional considerations are outlined below.
Please note:
⦁ It is your responsibility to keep your login details and password safe and secure. If you know or suspect that your record has been accessed by someone that you have not agreed should see it, then you should change your password immediately.
⦁ If you can’t do this for some reason, we recommend that you contact the practice so that they can remove online access until you are able to reset your password.
⦁ If you print out any information from your record, it is also your responsibility to keep this secure. If you are at all worried about keeping printed copies safe, we recommend that you do not make copies at all.
⦁ The practice may not be able to offer online access due to a number of reasons such as concerns that it could cause harm to physical or mental health or where there is reference to third parties. The practice has the right to remove online access to services for anyone that doesn’t use them responsibly.
Key considerations;
Forgotten history, There may be something you have forgotten about in your record that you might find upsetting.
Abnormal results or bad news, If your GP has given you access to test results or letters, you may see something that you find upsetting to you. This may occur before you have spoken to your doctor or while the surgery is closed and you cannot contact them.
Choosing to share your information with someone, It’s up to you whether or not you share your information with others – perhaps family members or carers. It’s your choice, but also your responsibility to keep the information safe and secure.
Coercion, If you think you may be pressured into revealing details from your patient record to someone else against your will, it is best that you do not register for access at this time.
Misunderstood information, Your medical record is designed to be used by clinical professionals to ensure that you receive the best possible care. Some of the information within your medical record may be highly technical, written by specialists and not easily understood. If you require further clarification, please contact the surgery for a clearer explanation.
Information about someone else, If you spot something in the record that is not about you or notice any other errors, please log out of the system immediately and contact the practice as soon as possible.
Please see the following link for further information;