Access To Your GP Medical Records
In line with national guidelines, we are enabling access to your online medical record for all adult patients for whom it is safe to do so. Access will be via the NHS app.
There are some patients, who are not able to make the decision to access medical information for themselves, who will not have access automatically switched on.
If you believe you should have access, but you do not, please contact the surgery. If you have access, and would like it switching off for any reason, then please contact the surgery.
For patients accessing their medical records we have provided the following FAQs in case you have questions or concerns about the information you are now seeing.
What happens if I am worried about a test result I have seen on the App?
The access you will receive will allow you to see blood results, laboratory reports, xray and scan reports and letters, as soon as they have been added to the digital system. This will mean there will be times when you can see a result before it has been seen by a GP or clinician. Results can be complex to interpret, for example a simple blood test for anaemia, reports on 7 different measurements; some of these could be slightly abnormal without there being any cause for concern. However seeing these results which look abnormal, before a doctor has analysed them could cause significant stress and anxiety.
At Skerne Medical Group, we ask our clinicians to file their blood and laboratory reports by their next working day. This can mean that if a clinician does not work every day a result may wait 2-3 days to be filed. Once a result has been filed a clinician will state what action needs to be taken: for example a result may be normal or satisfactory with no action needed, or abnormal. Abnormal results may be something serious or minor. When a clinician files a result that shows something serious and abnormal they will either contact the patient directly requesting to speak to them the same day or week, or they would ask the reception team to contact you. When a clinician files a result as abnormal, for something less worrying or minor, they may ask to speak to you routinely. So if a clinician has asked for routine follow up, this does means that there is no immediately necessary action needed.
Letters received by the practice are actioned in the same way, but because they are usually less urgent, they may take a longer period before being filed. We aim to file all letters within 10 working days.
In the case of both reports, results and letters, if something is thought to be immediately life threatening then the hospital would contact the practice directly and the result would not wait for routine filing.
Gaining early access to the results, must not be used as a way to seek priority for the actioning of your results. This creates unfairness in the system, and repeated contacts to the surgery to ask if a result/letter has been filed yet, prevents people who need immediate care from accessing us.
What if information I shared with the doctor is not in my notes?
The notes entries made by clinicians at Skerne Medical Group are a summary of the information that the clinician considers to be clinically important. They are not a ‘word-for-word’ copy of the consultation that you had. They may contain abbreviations. They may sometimes contain quotes or observations. This information can be very helpful in communicating to other team members to help give you continuity of care.
What if I disagree with something in my notes?
There may sometimes be things that you think are not relevant, or impressions of your behaviour that you disagree with, however this information is important and will not be changed if you disagree. Documentation of these things can give us a clearer idea of your mental-state or wellbeing at the time of the consultation. It can also allow us to look back and see how things have changed over time, for example if an unusual behaviour is out-of-character for you, or not. It can also help us to safeguard vulnerable patients. For example it would not be unusual to comment in the notes if someone seemed agitated or upset, or if someone looked unkempt.
Finally if someone is rude, aggressive, or impolite, this is also often recorded in the notes. As with other entries, it can give an insight into your wellbeing or mental state at the time of the consultation, however it is also important to note that the practice has a zero tolerance approach to abuse of staff.
Why are there entries in my notes from non-clinical staff?
Our Reception, Administrative and Secretarial staff are valued members of our team. There are times when they are expected to make entries in your notes. This could be a message received from a pharmacy or specialist. It could also be a comment on an encounter that they have had with you. This provides valuable information to our clinical team, and helps us to safeguard vulnerable patients. Our Reception, Administrative and Secretarial staff are expected to follow the same standards of confidentiality as all clinical staff in regards to patient notes.
If someone is rude, aggressive, or impolite, we would also expect our Administrative staff to note this as well. As with other entries, it can give an insight into your wellbeing or mental state at the time, however it is also important to note that the practice has a zero tolerance approach to abuse of all staff members.
Why can I not see an entry in my notes?
As part of the NHS England plan for prospective (future) notes access clinical staff can redact (hide) notes entries from the visible part of your record. This is something that would only be done in a situation where we believed that having access to the information would put you, or someone else at risk of harm. For example if you disclosed that someone else had access to your NHS App and might use information from a consultation against you. However the ability to redact (hide) data is limited, and we know that if you ever changed practices in future things that the redacted (hidden) notes entries might become visible.
Should I allow family/carers to have access to my NHS App
We know that there are times when people may have shared access or passwords for their NHS app, for example to allow someone else to order their prescription. By gaining prospective (future) access to your GP record via the NHS App anyone else who had this password would be able to see your full record. This could include highly sensitive information about matters such as fertility, abortion or sexual health. It could also include access to information about your mental health and wellbeing, for example if you were experiencing stress because of a relationship. There are other confidential health matters that you may also wish to keep private.
You should also be aware that the government are working to provide historic notes access via the app as well, so granting access to someone today, could mean that in future they can see historic as well as current and future entries in your record.