SHARING OF PATIENT INFORMATION

GENERAL PRINCIPLES

Whilst it is vital for the proper care of individuals that those concerned with that care have ready access to the information that they need, it is also important that service users and their carers can trust that personal information will be kept confidential and that their privacy is respected.

All staff have an obligation to safeguard the confidentiality of personal information. This is governed by law, their contracts of employment and in many case, professional codes of conduct. All staff should be aware that breach of confidentiality could be a matter for disciplinary action and provides grounds for a complaint against them.

Although it is neither practicable nor necessary to seek an individual's consent each time that information needs to be shared or passed on for a particular purpose, THAT HAS BEEN DEFINED WITHIN THIS POLICY this is contingent on individuals having been fully informed of the uses to which information about them may be put. All agencies concerned with the care of the individual should satisfy themselves that this requirement is met.

Clarity about the purpose to which personal information is to be put is essential and only the minimum identifiable information necessary to satisfy that purpose should be made available. Access to personal information should be on a need to know basis.

If an individual wants information about themselves to be withheld from someone or some agency which might otherwise have received it, the individual's wishes should be respected unless there are exceptional circumstances. Every effort should be made to explain to the individual the consequences for care and planning but the final decision should rest with the individual.

The exceptional circumstances which may override the above clause arises when information is required by statute or court order or where there is a serious public health risk or harm to other individuals or for the prevention, detection or prosecution of serious crime. The decision to release information in these circumstances, where judgment is required should be made by the senior partner and it may be necessary to seek legal advice.

There are also some statutory restrictions on the disclosure of information relating to AIDS, HIV and other sexually transmitted diseases, assisted conception and abortion.

Where information on individuals has been aggregated or anonymised, it should still only be used for justified purposes but is not governed by this policy. Care should be taken to ensure that individuals cannot be identified from this type of information as it is frequently possible to identify individuals from limited data e.g. age and post code may be sufficient.


SHARING PATIENT AND CARER INFORMATION

a) Verbal permission must be obtained from patient/client and carer before divulging information. In certain cases, written consent should be obtained.

b) Clarify to patient/client/carer, with whom information will be shared.

c) Get positive permission to share information.

d) Verbal permission must be documented in patient/client's medical record.

e) Written permission must be filed in patient/clients notes

f) Medical information is accessed on "need to know" basis in order to perform duties and no other. - see Defining Purpose

g) Staff confidentiality form signed as part of induction programme and is contained in employee's contract of employment.

Mechanisms for sharing information

a) Clinical Meetings
b) Face to face discussion
c) Message slips
d) Memos
e) Computer data
f) Team meetings

DEFINING PURPOSE

There will be a range of justifiable purposes to be locally agreed. The following list is not exhaustive and cover internal practice purposes only.

• delivering personal care and treatment
• assuring and improving the quality of care and treatment
• monitoring and protecting public health
• managing and planning services
• risk management
• investigating complaints
• teaching
• statistical analysis
• research (medical or health services)


HOLDING INFORMATION ACCESS AND SECURITY

• The practice will ensure they address the issues of security of information.

• The practice will take all reasonable care to protect both the physical security of information technology and the data contained within it.

• All information systems will be password protected

• All personal files must be kept secure.


OWNERSHIP OF INFORMATION AND THE RIGHTS OF INDIVIDUALS

Whilst written and computerised records will be regarded as shared between the agencies, an individual's right of access to the information contained in the records differs when it has been provided by a health professional from when it has been provided by social service staff.

Any health professional contribution to records maintained by social service staff, whether a letter, a case record or report, must be clearly marked as such and, where practicable, kept in a closed part of the file. Social service staff should not grant access to this information without written authorisation.