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.
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