Patient Record

Online Access to Your Medical Records

 

If you wish to, you can request access to view your medical records online through Systm-online.   

Being able to view your record online might help you to manage your medical conditions.  You may also find it useful to be able to access information in your record that you may need, such as your medication or immunisation history.

There are two types of access to your medical records you can view

1. Detailed Coded Record Access

This will include access to view all the clinically coded information in your records - such as problems, procedure codes, diagnoses, medication, test results, immunisations and allergies. You will be able to see when a referral has been made or a letter received, but not be able to read the contents of the letter.

Clinical codes are similar to topic headings in a book, they will give you information about what that consultation or entry was in relation too without the very specific information that the doctor or nurse typed into your records.  This is called Detailed Coded Record Access.

2. Full Clinical Record Access

This type of access will include all the information seen for those patients with Detailed Coded Record Access, but will also allow you to read free text entries in your records and attachments such as hospital letters.

 

It will be 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 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.

Things to Consider before Applying for Online Access

 

Before you apply for online access to your medical record, there are some other things to consider:

1. Forgotton History

There may be something you have forgotten about in your record that you might find upsetting.

2. 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.

3. 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.

4. 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.

5. 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.

6. 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.

Sharing Your Medical Record

Increasingly, patient medical data is shared e.g. between GP surgeries and District Nursing, in order to give clinicians access to the most up to date information when attending patients.

The systems we operate require that any sharing of medical information is consented to by patients beforehand. Patients must consent to sharing of the data held by a health provider out to other health providers and must also consent to which of the other providers can access their data.

e.g. it may be necessary to share data held in GP practices with district nurses but the local podiatry department would not need to see it to undertake their work. In this case, patients would allow the surgery to share their data, they would allow the district nurses to access it but they would not allow access by the podiatry department. In this way access to patient data is under patients' control and can be shared on a 'need to know' basis.

Summary Care Record

There is a new Central NHS Computer System called the Summary Care Record (SCR). The Summary Care Record is meant to help emergency doctors and nurses help you when you contact them when the surgery is closed. Initially, it will contain just your medications and allergies.

Later on as the central NHS computer system develops, (known as the ‘Summary Care Record’ – SCR), other staff who work in the NHS will be able to access it along with information from hospitals, out of hours services, and specialists letters that may be added as well.

Your information will be extracted from practices such as ours and held on central NHS databases.   

As with all new systems there are pros and cons to think about. When you speak to an emergency doctor you might overlook something that is important and if they have access to your medical record it might avoid mistakes or problems, although even then, you should be asked to give your consent each time a member of NHS Staff wishes to access your record, unless you are medically unable to do so.

On the other hand, you may have strong views about sharing your personal information and wish to keep your information at the level of this practice. Connecting for Health (CfH), the government agency responsible for the Summary Care Record have agreed with doctors’ leaders that new patients registering with this practice should be able to decide whether or not their information is uploaded to the Central NHS Computer System.

For existing patients it is different in that it is assumed that you want your record uploaded to the Central NHS Computer System unless you actively opt out.