Patient Confidentiality and Health Records

Confidentiality: NHS Code of Practice

This document is a guide to required practice for those who work within or under contract to NHS organisations concerning confidentiality and patients’ consent to the use of their health records.

Confidentiality: NHS Code of Practice
Supplementary Guidance: Public Interest Disclosures

This document expands upon the principles set out with the Department of Health’s key guidance Confidentiality: NHS Code of Practice. The document is aimed at aiding staff in making difficult decisions about when disclosures of confidential information may be justified in the public interest.

• Source: gov.uk
• Pharmacy Resource: Guidance and Supplementary Guidance
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General Pharmaceutical Council Guidance On Patient Confidentiality

This guidance explains to pharmacy professionals (pharmacists and pharmacy technicians) the importance of maintaining confidentiality, and their relevant responsibilities. Pharmacy professionals should use their professional judgement in applying this guidance.

• Source: pharmacyregulation.org
• Pharmacy Resource: Guidance
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Data Protection Act 2018

• Source: legislation.gov.uk
• Pharmacy Resource: Act
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Guide to Data Protection
Information Commissioner’s Office

This guide is for data protection officers and others who have day-to-day responsibility for data protection. It is aimed at small and medium-sized organisations, but it may be useful for larger organisations too.

• Source: ico.gov.uk
• Pharmacy Resource: Guidance
• Register to Access Content: No

Access to Health Records Act 1990

• Source: legislation.gov.uk
• Pharmacy Resource: Act
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Access to Medical Reports Act 1988

• Source: legislation.gov.uk
• Pharmacy Resource: Act
• Register to Access Content: No

Patient health records and confidentiality

House of Commons Library briefing on access to patient health records, electronic patient records, NHS data security, and the use of confidential information by the NHS.

This briefing describes how patients may request access to their records, and the circumstances in which access to the records of others may be allowed, including new requirements introduced by the EU General Data Protection Regulation (GDPR) and the Data Protection Act 2018. It also describes statutory and public interest disclosures of patient information; information sharing rules for people who lack mental capacity; and access to information on hereditary conditions for relatives.

• Source: researchbriefings.parliament.uk
• Pharmacy Resource: Briefing
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Access to health records
Guidance for health professionals in the United Kingdom
British Medical Association

The guidance covers the following areas:

• defining a health record
• advice on record-keeping
• subject access requests
• requests for access on behalf of others
• requests by the police
• requests by insurers
• requests for access to the records of deceased patients
• records retention

• Source: bma.org.uk
• Pharmacy Resource: Guidance
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Access to medical reports
Guidance from the British Medical Association Medical Ethics Department

Patients have the right to see reports written about them by a doctor with whom they have a normal doctor-patient relationship.

This guidance includes advice on the following issues:

• Legislation
• Consent
• Individuals’ rights
• Seeing the report
• Amendments
• Fees
• Withholding information
• Doctors’ responsibilities
• Failure to comply with the legislation

• Source: bma.org.uk
• Pharmacy Resource: Guidance
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Recommendations for Retention of Pharmacy Records

This document is a collation of information on legal requirements and national guidance for retention of pharmacy records. It is intended as a comprehensive but concise first point of reference for pharmacy professionals and as an aid to local decision making. In some circumstances more than one piece of legislation is relevant to a specific
record or situation and requirements of each may appear to conflict with one another. Where no relevant legal requirement or national guidance has been identified, a ‘best practice’ recommendation may be given.

• Source: sps.nhs.uk
• Pharmacy Resource: Recommendations
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Summary Care Records – England

This guidance has been developed in collaboration with and has been endorsed by NHS Digital and Company Chemists Association

Usage of the SCR by pharmacy professionals remains low. We understand misinformation has been generated and often it isn’t quite clear how and when you can access the SCR. This quick reference guide will support you in understanding how SCR can be used and also help dispel myths and misconceptions surrounding SCR.

• Source: rpharms.com
• Pharmacy Resource: Guide
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Permission to view Summary Care Records in community pharmacy

Find out how to get permission to view a patient’s Summary Care Record (SCR)

• Source: digital.nhs.uk
• Pharmacy Resource: Guide
• Register to Access Content: No

Summary Care Records 

The NHS Summary Care Record (SCR) is an electronic summary of key clinical information (including medicines, allergies and adverse reactions) about a patient, sourced from the GP record.

• Source: psnc.org.uk
• Pharmacy Resource: Various
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Confidentiality and health records tool kit
British Medical Association

As a doctor you face increasingly complex dilemmas arising from your duty to protect patient confidentiality.

The list of demands on you to give information to third parties is ever-growing – from insurers, the police, social workers, the DVLA and the relatives of deceased patients.

Our tool kit is your starting point to find out the key issues to take into account when making decisions on confidentiality.

It is made up of 16 cards covering specific areas of confidentiality relating to children, adults who lack capacity and the deceased as well as the secondary uses of information.

• Source: bma.org.uk
• Pharmacy Resource: Toolkit
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The Care Record Guarantee

The NHS Care Record Guarantee for England sets out the rules that govern how patient information is used in the NHS and what control the patient can have over this. It covers people’s access to their own records; controls on others’ access; how access will be monitored and policed; options people have to further limit access; access in an emergency; and what happens when someone cannot make

• Source: webarchive.nationalarchives.gov.uk
• Pharmacy Resource: Publication
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Information: To share or not to share? The Information Governance Review

Following a request from the Secretary of State for Health, Dame Fiona Caldicott carried out this independent review of information sharing to ensure that there is an appropriate balance between the protection of patient information and the use and sharing of information to improve patient care.

• Source: gov.uk
• Pharmacy Resource: Review
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Information: To share or not to share? Government Response to the Caldicott Review

The government accepts all the recommendations of the Caldicott report and highlights that while information sharing is essential to provide good care for everyone, there are rules that must be followed.

The ambitions of this response are that:

• everyone will feel confident that information about their health and care is secure, protected and shared appropriately when that is in their interest
• people will be better informed about how their information is used and shared while they are receiving care, including how it could be used in anonymised form for research, for public health and to create better services
• if people don’t want their information to be shared in this way, they will know how to object if they want to
• people will be increasingly able to access their own health and care records

• Source: gov.uk
• Pharmacy Resource: Response
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A Manual for Caldicott Guardian Manual

The UK Caldicott Guardian Council (UKCGC) has produced A Manual for Caldicott Guardians. It is intended to be a starting point for newly-appointed Caldicott Guardians, a refresher for the more experienced, and a pointer to possibilities for professional development and support.

• Source: gov.uk
• Pharmacy Resource: Manual
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Think privacy toolkit

The TH!NK PRIVACY campaign has been created to aid the communication of the challenge faced by organisations of all sizes, to their employees – reminding staff to ‘press the mental pause button’ before taking action.

TH!NK PRIVACY offers a range of free downloadable materials including posters, bin stickers and postcards, for use within your organisation. You can print them off for use in employee areas.

• Source: ico.gov.uk
• Pharmacy Resource: Toolkit
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PSNC briefing on confidentiality, data protection and human rights

As part of the clinical governance requirement in the NHS pharmacy contract, staff and employees need to comply with legal obligations on data protection and confidentiality, including the Human Rights Act.

• Source: psnc.org.uk
• Pharmacy Resource: Briefing
• Register to Access Content: No

Guide to information provided by pharmacy businesses under the model publication scheme

The template lists the information that we think pharmacy businesses hold and should make available within each class. When completed, this will provide a list of all the information the pharmacy business will make routinely available, explain how it can be accessed and whether or not a charge will be made for it. They must:

• state how the specific information can be obtained and if there is a cost involved;
• complete the relevant columns in the template guide; and
• ensure the public can access the completed guide and the information listed in it.

• Source: ico.gov.uk
• Pharmacy Resource: Template
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Confidentiality and Data Protection staff declaration

• Source: psnc.org.uk
• Pharmacy Resource: Template
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Information Governance : PSNC

Providers of NHS services within England, including community pharmacy contractors, are required to give information governance assurances to the NHS each year via the online self-assessment

• Source: psnc.org.uk
• Pharmacy Resource: Various
• Register to Access Content: No

Information about the deceased

Health organisations often get freedom of information requests relating to the medical records of the deceased. There are no special exemptions under the Act about the deceased, but you do need to consider whether the information is sensitive.

• Source: ico.gov.uk
• Pharmacy Resource: Guidance
• Register to Access Content: No

Service Standards on Confidentiality

Published by the Clinical Standards Committee

Faculty of Sexual & Reproductive Healthcare of the Royal College of Obstetricians and Gynaecologists

• Source: fsrh.org
• Pharmacy Resource: Standards
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Best practice guidance for doctors and other health professionals on the provision of advice and treatment to young people under 16 on contraception, sexual and reproductive health

Doctors and health professionals have a duty of care and a duty of confidentiality to all patients, including under 16s.

This guidance applies to the provision of advice and treatment on contraception, sexual and reproductive health, including abortion.

Potential Q&As

All young people under 16 have a right to confidential advice from health professionals about sexual health/STIs, contraception and relationships.

• Source: webarchive.nationalarchives.gov.uk
• Pharmacy Resource: Guidance and Q&As
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