Access to medical records

The practice is bound by the Access to Medical Records Act 1990.

Applications under this Act must be made in writing to the practice explaining the purpose of your request.

Following receipt of your letter, we will send you a consent form. Then contact you to arrange for you to inspect relevant parts of the record and/or will be entitled to a copy of the record

Records Management Policy

1. 1. Introduction
      1.1.           The Practice needs to know where all information is to enable it to function and meet its statutory responsibilities.
      1.2.           The Freedom of Information Act 2000 requires all public organisations to implement an exemplar Code of Practice for Records Management based on the mandatory Code of Practice developed by the Lord Chancellor’s Office under Section 46 of the act.
      1.3.           This policy has been produced to ensure that information held within the Practice is readily identifiable and accessible to all those who have a legitimate need to see it to do their job.
   2. Regularity Framework
      2.1.           There is a direct and indirect regulatory framework governing Records Management:
      Direct – Section 46 of the Freedom of Information Act 2000
      The Lord Chancellor’s Code of Practice.
      Code of Openness in the NHS (1995)
      Public Records Act (1958)
      Welsh Health Circular (WHC) – Preservation, Retention, and Destruction of
      GP General Medical Services Records Relating to Patients
      For the Record – WHC (2000) 71
      2.2.         Indirect – good practice under:The Caldicott Report 1997
      The Data Protection Act 1998
      The Human Rights Act
      The Medical Records Act Principles
      The NHS Baseline IT Security Standards
   3. Scope

      3.1             This policy applies to all staff within the Practice.

   4. Guiding Principles
      4.1       Records Management will be the responsibility of the Lead GP.
      4.2       Records containing personal or patient identifiable information will be managed in accordance
      with the principles of the Data Protection Act.
      4.3       The Practice Manager must create an Electronic Central File and Tracking Index to record the
      location of all records held by the Practice, including Patient Medical Records.
      4.4       The Central File Tracking Index must contain details of all manual and computerised records
      created by the Practice.
      4.5       A nominated staff member will be responsible for the management and maintenance of the
      Central File Tracking Index.
      4.6       The Practice Manager must introduce a common file naming convention to be used for both
      paper and computerised records, with the file reference distinguishing between the type of
      record.
      4.7       The Central File Tracking Index must be able to identify the type of record, its classification,
      and where it is located at all times.
      4.8        Every Member of Staff must update the CFTI with details of:
      ·           Every new file created
      ·           Every file moved to different rooms or cabinets
      Everry file sent to the Business Services Centre
      ·           Every file or part record transferred or destroyed.

      4.9       Manual (Paper) Records
      4.9.1      The Practice Manager will develop the procedure for managing Manual (Paper) Records.

      4.10    Electronic (Computer) Records
      4.10.1    The Practice Manager will develop the procedure for managing Electronic (Computer) Records and including emails

      4.11    Retention and Destruction of Records
      4.11.1    Retention and Destruction of Records must be managed within the ruling NHS Guidelines –
      currently WHC (99) 7 and WHC (2000) 71, (due to be incorporated into the new DoH Code of Practice for Records Management in 2006), and the conditions of the Lord Chancellor’s Code of Practice.
      4.11.2    Records that have to be kept under the limitation act should be properly labelled and placed in a separately designated section of the manual or electronic record storage area (whichever is applicable).
      4.11.3    All records archived must be labelled properly by type, basic content and retention period.

      5          Responsible Officers
      5.1       The Lead GP must ensure that the resources devoted to records management are adequate for the work necessary. Management of the process will need to include the following (or personnel carrying out the duties) professional leads:
      ·              Data Protection Officer
      ·              Security Officer
      ·              Systems Manager
      ·              Caldicott Guardian.
      5.2       All aspects of the records management system must be reviewed at least annually.

      6          Training
      6.1       Every Member of Staff, including temporary or agency staff, will be required to attend a Records Management Awareness Session. This should form part of the Induction Process for permanent staff.