Practice Policies & Patient Information
Access to Records
In accordance with the Data Protection Act 1998 and Access to Health Records Act, patients may request to see their medical records. Such requests should be made through the practice manager and may be subject to an administration charge. No information will be released without the patient consent unless we are legally obliged to do so. An appointment will be made at a mutually convenient time for you to view your records.
Accessible Information Standard
The Accessible Information Standard aims to ensure that patients (or their carers) who have a disability or sensory loss receive information they can access and understand, for example in large print, braille or via email, and professional communication support if they need it, for example from a British Sign Language interpreter.
This applies to patients and their carers who have information and/or communication needs relating to a disability, impairment or sensory loss. It also applies to parents and carers of patients / service users who have such information and/or communication needs, where appropriate.
Individuals most likely to be affected by the Standard include people who are blind or deaf, who have some hearing and/or visual loss, people who are deaf blind and people with a learning disability. However, this list is not exhaustive.
There are five key requirements of the Standard:
1. Ask patients and carers if they have any information or communication needs, and find out how to meet their needs.
2. Record those needs in a set way.
3. Highlight a patient’s file, so it is clear that they have information or communication needs, and clearly explain how those needs should be met.
4. Share information about a person’s needs with other NHS and adult social care providers, when they have consent or permission to do so.
5. Make sure that people get information in an accessible way and communication support if they need it.
If you feel that this applies to you or someone in your care please complete the attached form and hand it in at the surgery or collect a form from surgery if you wish.
Further information can be found on:
Chaperone Policy
Introduction
This Policy is designed to protect both patients and staff from abuse or allegations of abuse, and to assist patients in making an informed choice about their examinations and consultations.
Guidelines
Clinicians (male and female) will consider whether an intimate or personal examination of the patient (either male or female) is justified, or whether the nature of the consultation poses a risk of misunderstanding.
- The Clinician will give the patient a clear explanation of what the examination will involve
- They will always adopt a professional and considerate manner and be careful with humour as a way of relaxing a nervous situation, as it can easily be misinterpreted
- The patient will always be provided with adequate privacy to undress and dress
- A suitable sign will be clearly on display in each Consulting or Treatment Room offering the Chaperone Service.
The above guidelines are to remove the potential for misunderstanding. However, there will still be times when either the Clinician, or the patient, feels uncomfortable, and it would then be appropriate to consider using a Chaperone.
Patients who request a Chaperone will never be examined without a Chaperone being present. If necessary, where a Chaperone is not available, the consultation/examination will be rearranged for a mutually convenient time when a Chaperone can be present.
Complaints and claims have not been limited to Doctors treating/examining patients of the opposite gender – there are many examples of alleged assault by female and male doctors on people of the same gender.
Consideration will always be given by staff to the possibility of a malicious accusation by a patient, and a Chaperone organised if there is any potential for this.
There may be occasions when a Chaperone is needed for a home visit in which case the following procedure will be followed.
Who can act as a Chaperone?
A variety of people can act as a Chaperone in the practice, but staff undertaking a formal Chaperone role will have been trained in the competencies required. Where possible, Chaperones will be clinical staff familiar with procedural aspects of personal examination.
Where the Practice determines that non-clinical staff will act in this capacity, the patient will be asked to agree to the presence of a non-Clinician in the examination, and for confirmation that they are at ease with this. The staff member will be trained in the procedural aspects of personal examinations, be comfortable acting in the role of Chaperone, and be confident in the scope and extent of their role. They will also have received instruction on where to sit/stand and what to watch and listen for. A Chaperone will document in the patient notes that they were present and detail any issues arising.
Confidentiality
- The Chaperone will only be present for the examination itself, with most of the discussion with the patient taking place while the Chaperone is not present.
- Patients are reassured that all Practice staff understand their responsibility not to divulge confidential information.
Procedure
- The Clinician will contact reception to request a Chaperone
- Where no Chaperone is available, a Clinician may offer to delay the examination to a date when one will be available, as long as the delay would not have an adverse effect on the patient’s health
- If a Clinician wishes to conduct an examination with a Chaperone present but the patient does not agree to this, the Clinician will explain clearly why they want a Chaperone to be present. The Clinician may choose to consider referring the patient to a colleague who would be willing to examine them without a Chaperone, as long as the delay would not have an adverse effect on the patient’s health
- The Clinician will record in the notes that the Chaperone is present, and identify the Chaperone
- The Chaperone will enter the room discreetly and remain in the room until the Clinician has finished the examination
- A Chaperone will attend inside the curtain/screened-off area at the head of the examination couch and observe the procedure
- To prevent embarrassment, the Chaperone will not enter into conversation with the patient or GP unless requested to do so, or make any mention of the consultation afterwards
- The Chaperone will make a record in the patient’s notes after examination. The record will either state that there were no problems, or give details of any concerns or incidents that occurred. The Chaperone must be aware of the procedure to follow if any concerns require to be raised
- The patient can refuse a Chaperone, and if so this must be recorded in the patient’s medical record.
Complaints
We make every effort to give the best service possible to everyone who attends our practice.
We would ask that you contact the practice to discuss your complaint first to see if we can sort it out using local resolution procedures. A leaflet about complaints, and a copy of the complaints procedure can be obtained from reception.
However, we are aware that things can go wrong resulting in a patient feeling that they have a genuine cause for complaint. If this is so, we would wish for the matter to be settled as quickly, and as amicably, as possible.
To pursue a complaint please contact the practice manager who will deal with your concerns appropriately, you may be asked to detail your complaint in writing. Further written information is available regarding the complaints procedure from reception. All complaints are investigated and we will always provide you with a full written response within 21 days of receiving your complaint (your complaint will be acknowledged within 2 working days).
The following organisations can help you with complaints about the NHS:
- Patients Advice And Liaison Service PALS
Tel: 0800 028 3693
Address: PALS, Newark and Sherwood CVS, 67 Northgate, Newark, NG24 1HD
Email: [email protected]
POhWER – NHS Complaints Advocacy Service
Website: www.pohwer.net/in-your-area/where-you-live/Lincolnshire
Telephone: 0300 456 2370
Email: mailto:[email protected]
Or you may contact NHS England complaints team. They can be contacted on;
- Tel: 0300 311 22 33
- or by email at [email protected]
The Health Service Ombudsman in England
The Parliamentary and Health Service Ombudsman website contains detailed information on raising a complaint about any aspect of the NHS in England.
Confidentiality & Medical Records
The practice complies with data protection and access to medical records legislation. Identifiable information about you will be shared with others in the following circumstances:
To provide further medical treatment for you e.g. from district nurses and hospital services.
- To help you get other services e.g. from the social work department. This requires your consent.
- When we have a duty to others e.g. in child protection cases anonymised patient information will also be used at local and national level to help the Health Board and Government plan services e.g. for diabetic care.
If you do not wish anonymous information about you to be used in such a way, please let us know.
Reception and administration staff require access to your medical records in order to do their jobs. These members of staff are bound by the same rules of confidentiality as the medical staff.
Freedom of Information
Information about the General Practioners and the practice required for disclosure under this act can be made available to the public. All requests for such information should be made to the practice manager.
Gluten Free Policy
Patient information
If you have been diagnosed with coeliac disease then it’s important to talk to your doctor about what this means. Ask him or her to refer you to a Registered Dietitian for advice on what you can and can’t eat. Information to help you learn more about how best to manage your diet and health is also available on NHS Choices website and the Coeliac UK website
www.nhs.uk/conditions/coeliac-disease and www.coeliac.org.uk
This policy applies to all patients. However, special cases will be considered on an individual patient basis. Where a patient’s GP considers that a patient would receive additional benefit from NHS treatment when compared to other patients with the same clinical condition, they will be able to refer into a central CCG panel for the case to be considered.
Any queries about this policy should be directed to the CCGs Patient Engagement Team on 0800 028 3693; email [email protected] or in writing to Patient Experience Team, NHS Newark and Sherwood Clinical Commissioning Group, Balderton Primary Care Centre, Lowfield Lane, Balderton, Nottinghamshire NG24 3HJ.
For Further information please see resources below:
GP Net Earnings
All GP practices are required to declare the mean earnings (e.g. average pay) for GPs working to deliver NHS services to patients at each practice.
NHS England require that the net earnings of doctors engaged in the practice is publicised, and the required disclosure is shown below. However it should be noted that the prescribed method for calculating earnings is potentially misleading because it takes no account of how much time doctors spend working in the practice, and should not be used to form any judgement about GP earnings, nor to make any comparison with any other practice.
The average earnings for GPs working in Major Oak Medical Practice in the last financial year was £107,699 before taxation and National Insurance. This is for four GPs who worked in the practice for more than 6 months during tax year 2019-20.
Information Sharing / the National Opt-out programme
Information Sharing – Sharing Your GP Record
Caring by sharing – supporting your healthcare at all times
Many people think their GP Record is available to all healthcare professionals involved in their care; but this is not generally the case. It is very common that each healthcare professional you see keeps a separate electronic record about you. This can mean important information may not be communicated between health services as well as it could be.
From time to time it is therefore helpful for us to be able to share information about your health and care requirements with other health organisations that are providing you with direct healthcare. Across Nottinghamshire we are introducing a local GP Record sharing model which will allow us to make relevant medical information from your GP Record available to other healthcare professionals at the point of need when they are providing care for you. However you will be asked for consent at the point of contact for your GP information to be viewed by a care professional outside your GP practice.
You will always be asked for your explicit consent before healthcare professional accesses your GP Record. If you say “No” the care professional will not be able to see your medical information. However there may be exceptional/emergency situations (e.g. if you were unconscious) where a health professional may access your GP record if deemed in your best interests to provide care.
Examples of organisations that may access your GP health information include Out of Hours Teams, Walk in Centres, Hospitals /A&E Departments and Community Healthcare Teams.
Making your GP record available in this way is designed to ensure that the healthcare professionals looking after you have the most relevant up to date information to enable them to provide you with the most appropriate care. It may also mean that you won’t have unnecessary tests, have to repeat information or be given drugs that you may be allergic to for example.
If you wish to only make certain parts of your GP record available and not all of it then you can ask for sections of your GP Record to be marked as ‘Private’. Private information will never be shared unless it is required by law or you give permission.
Please be assured your personal and sensitive health information will be kept confidential and secure at all times and only be used for your direct care purposes.
We would encourage everyone to make their GP Record available in case they need to be seen in an emergency or Out of Hours. If you have certain health conditions or go to hospital a lot then you should definitely make your record available.
You can download the consent form here.
How information about you helps us to provide better care
Information about you and the care you receive is shared, in a secure system, by healthcare staff to support your treatment and care.
It is important that we, the NHS, can use this information to plan and improve services for all patients. We would like to link information from all the different places where you receive care, such as your GP, hospital and community service, to help us provide a full picture. This will allow us to compare the care you received in one area against the care you received in another, so we can see what has worked best.
Information such as your postcode and NHS number, but not your name, will be used to link your records in a secure system, so your identity is protected. Information which does not reveal your identity can then be used by others, such as researchers and those planning health services, to make sure we provide the best care possible for everyone.
How your information is used and shared is controlled by law and strict rules are in place to protect your privacy. We need to make sure that you know this is happening and the choices you have.
Can I opt out?
If you are happy for your information to be shared you do not need to do anything. There is no form to fill in and nothing to sign and you can change your mind at any time.
To opt oit please write to the practice manager and explain that you wish to descent to having your data included in the care data process. We will then document it in your records to ensure your data will not be used.
Where can I get more information?
The NHS has produced a care data leaflet and FAQs sheet
You can also get further information from the website at www.hscic.gov.uk
Your Data Matters to the NHS
Information about your health and care helps us to improve your individual care, speed up
diagnosis, plan your local services and research new treatments.
In May 2018, the strict rules about how this data can and cannot be used were strengthened. The NHS is committed to keeping patient information safe and always being clear about how it is used.
You can choose whether your confidential patient information is used for research and planning.
To find out more visit:
nhs.uk/your-nhs-data-matters
Named Accountable GP
From 1st April 2015 onwards Practices are required, under the GMS contract, to allocate a named accountable GP to all patients, including children.
Having a named accountable GP does not prevent you from seeing another doctor at the practice. Your named GP will not be available at all times and if you need to be seen urgently you may wish to see another doctor. All of your records are viewable by every doctor in the Surgery.
This does not change the way in which we operate or affect your ability to make an appointment or speak with any of the GPs in the practice.
We have now allocated all patients to a named GP. Patients is allocated on a by surname basis based on the number of clinics a doctor runs per week:
Patients with a surname beginning A – L: Dr Wageeh Mikhail
Patients with a surname beginning M – S: Dr Gopinath Singaravel
Patients with a surname beginning T – Z: Dr Emad Gabrawi
New patients registering from 1st April 2015 onwards will be allocated at point of registration.
Should you express a wish to change your named GP we will do our best to accommodate your wishes. Please write to the Practice Manager requesting the change.
Please note: there is no need to telephone the practice for this information.
Privacy Notice
Sharing Information
From time to time it is helpful for us to be able to share information about your health and care requirements with other health organisations that are responsible for some of your health care. Across Nottinghamshire we are introducing a new system called MIG (Medical Interoperability Gateway) which will enable us to share relevant medical information, on a view only basis, with clinicians in other healthcare organisations who are involved with your care; for example the CNCS Out of Hours team and local A&E departments.
Sharing of information in this way is designed to ensure that the healthcare professional looking after you has the most relevant information to enable them to provide you with the most appropriate care. The type of information shared is restricted and includes a summary of current problems, current medication, allergies, recent tests, diagnosis, procedures, investigations, risks and warnings – all this information is currently held in your GP system record.
Whenever a clinician from another healthcare organisation wishes to view your record they will always seek your permission before doing so; if you say “NO” they will not be able to see any information from your GP record during the episode of care.
Summary Care Record & GP2GP
There is a new Central NHS Computer System called the Summary Care Record (SCR). It is an electronic record which contains information about the medicines you take, allergies you suffer from and any bad reactions to medicines you have had.
Why do I need a Summary Care Record?
Storing information in one place makes it easier for healthcare staff to treat you in an emergency, or when your GP practice is closed.
This information could make a difference to how a doctor decides to care for you, for example which medicines they choose to prescribe for you.
Who can see it?
Only healthcare staff involved in your care can see your Summary Care Record.
How do I know if I have one?
Over half of the population of England now have a Summary Care Record. You can find out whether Summary Care Records have come to your area by looking at our interactive map or by asking your GP
Do I have to have one?
No, it is not compulsory. If you choose to opt out of the scheme, then you will need to complete a form and bring it along to the surgery. You can use the form at the foot of this page.
More Information
For further information visit the NHS Care records website or the HSCIC Website
GP2GP
ELECTRONIC TRANSFER OF PATIENT RECORDS BETWEEN PRACTICES
Statement of Intent
New contractual requirements from 1 April 2014 state that Practices should make available a statement of intent in relation to GP2GP (the transfer of patient medical records).
The Government requires all practices to use the electronic GP2GP facility for transferring patients records between practices when the patient registers or de-registers (not temporary registrations) by March 2015.
From 15th January 2015, Major Oak Medical Practice will be using this facility for all transfers of patient records unless there is an issue with the receiving practice’s computer system which does not allow or provide such transfers.
Transferring your electronic health record
Your GP practice holds copies of your patient health record electronically and in paper format. Both contain the healthcare information about you that your GP needs including your medical history, medications, allergies, immunisations and vaccinations.
If you have previously registered with a different GP in England, upon registering at this practice your electronic health record will, where possible, be transferred automatically from your previous practice through the use of an NHS system called GP2GP.
Patient benefits
When patients move practices, paper medical records can take weeks to arrive but GP2GP transfers are faster, more reliable and more secure than the existing paper-based method of transferring patient records. This means your new practice will have your full and detailed medical record available in time for your very first appointment.
Frequently asked questions
What is GP2GP?
GP2GP is the technology that transfers your electronic health record directly and securely from your previous GP when you register at this practice.
Does my old practice need to be using GP2GP for my electronic health record to be transferred electronically?
Yes, both practices need to be using GP2GP. If they are not, only your paper medical record will be sent and will include a print-out of your electronic health record from your previous practice.
What happens to my paper record?
Your paper medical record will also be transferred to this practice. This usually takes about six to eight weeks. In the future when all practices are using GP2GP the need for sending paper records may be reviewed.
What information will be transferred in my electronic health record?
The information contained within your electronic health record at your previous practice will be transferred. This includes information about your medications, allergies, adverse reactions, immunisations and vaccinations, laboratory results, diagnoses, medical history and letters from specialists.
Will my repeat prescriptions be automatically transferred as well?
Yes, GP2GP transfers all the information about your medications. Your new GP will review all the medicines you are taking before authorising any repeat prescription.
I am registering as a temporary resident. Will my electronic health record still be transferred electronically?
No. If you are registering as a temporary resident your health records remain at your usual practice and are not transferred either as paper or via GP2GP. Your temporary practice will contact your registered GP if they require any information.
Where can I find out more about GP2GP?
You can read about GP2GP on the Health and Social Care Information Centre website: GP2GP – NHS Digital.
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