Patient records

The principles adopted by this Trust as set out in the NHS Care Record Guarantee.

In the NHS in England, we aim to provide you with the highest quality of health care. To do this, we must keep records about you, your health and the care we have provided to you or plan to provide to you. This guarantee is our commitment that we will use records about you in ways that respect your rights and promote your health and wellbeing.

We use your records to:

• provide a good basis for all health decisions made by you and care professionals;
• allow you to work with those providing care;
• make sure your care is safe and effective; and
• work effectively with others providing you with care.

Others may also need to use records about you to:

• check the quality of care (such as a clinical audit);
• protect the health of the general public;
• keep track of NHS spending;
• manage the health service;
• help investigate any concerns or complaints you or your family have about your health care;
• teach health care workers; and
• help with research.

You have the right:

• to confidentiality under the Data Protection Act 1998, the Human Rights Act 1998 and the common law duty of confidence (the Disability Discrimination and the Race Relations Acts may also apply);
• to ask for a copy of all records about you (you may have to pay a fee).

We have a duty to:

• maintain full and accurate records of the care we provide to you;
• keep records about you confidential, secure and accurate; and
• provide information in a format that is accessible to you (for example, in large type if you are partially sighted).

What information do we collect?

When a call is received in one of the Ambulance Trust control rooms information is recorded and stored that identifies the source of the call as well as the answers to the questions asked of the caller.

This will include the address or location where the patient is and the details of the problems or condition of the patient together with an outline of the incident.   

Once our staff meet the patient we record clinical details to include the history of what happened, the problems the patient is experiencing and the details of the examination undertaken by our staff. We then record the treatment given or suggested together with any advice given to the patient or those helping or responsible for the patient.

How do we protect patient details and information we hold?

All ambulance staff have within their contract of employment a clause explaining the importance of protecting patient information and this clause makes it explicit that patient information may be divulged except in the context of providing direct patient care

The Trust observes the Caldcott principles and has both a Data Protection Officer and Caldicott Guardian responsible for the protection of patient information

Every flow of patient-identifiable information should be regularly justified and routinely tested against the principles developed in the Caldicott Report. The six Caldicot Principles state that

• Principle 1 - Justify the purpose(s) for using confidential information
• Principle 2 - Only use it when absolutely necessary
• Principle 3 - Use the minimum that is required
• Principle 4 - Access should be on a strict need-to-know basis
• Principle 5 - Everyone must understand his or her responsibilities
• Principle 6 - Understand and comply with the law

Why do we collect it?

The details of each call to our control rooms are collected so that the Ambulance Trust can respond in a timely and appropriate way. The Trust needs to be able to prioritise the calls it receives so that those to life threatening situations receive the most appropriate and speedy response. While those of a lesser nature may be given differing advice after further discussion with our clinical advisors

Once with the patient it is essential that all relevant clinical and demographic details are checked and recorded. This will include all the answers from the patient and other able to explain what has happened together with the examination and conclusions reached. The treatments provided and advice given will be recorded.

We have a duty, as do all NHS clinical staff to document all patient details accurately to support the care we provide. This will support not only the care our staff have provided but will contribute to the on-going care the patient may require

The purpose is therefore to demonstrate good clinical practice and facilitate on-going care. The link between good clinical records and high standards of care provided has been established in many research projects       

How do we collect it?

In answer to the questions asked on the telephone to our control room staff, all data is entered on to a computer system and additionally is audio recorded

Our clinical staff will either create a paper record or an electronic patient record. Presently the electronic record is not connect to any other system and the details recorded remain the property of the Trust and are not shared.

The Trust has a very tight policy on the use of cameras and recording of visual images and abides by the GMC advice on the acquisition, storage, retrieval and use of such images

What do we do with the information?

The information is used to ensure the correct response arrives at the patient or appropriate advice is given to the caller

For the clinical information that is collected this is either given to the patient so that they can retain the details and use in the future if required or it is passed onto those who will provide ongoing care to the patient be that the hospital service or primary care service. If it is determined that social service care is required then appropriate patient details will be passed to social services.

Otherwise the ambulance records are achieved and stored according to the NHS Patient Record Guidance.

The Trust complies with national requirements to provide case details (annonymised) for audit purposes.

If we are ever asked to supply patient details by a third party this will only happen if we have the express written permission of the patient or the person who has ownership of the data

Do we ever disclose patient data without the express written permission – yes we do but only in very controlled settings. This will only occur on a request by request basis decide by the Caldicott Guardian. These include

• disease reporting required by Law
• to the Coroner
• in the public interest
• in the investigation of a serious crime or to prevent a serious criminal act
• Child protection

We also use annonymised data to improve our services and educational programmes.

If we share information with other organisations to provide ongoing health care or management of services then this will only be undertaken if an Information sharing policy is in place – the purpose of such a policy is to ensure if information is passed to a third part then it will be used according to the Caldicott Principles and the data is still protected as though it were still owned by the Trust.

The Trust operates within the principles as set down at the top of this section (NHS Care Record Guarantee) and information gathered may not be used for other purposes unless the patient has given express written permission for the purpose that is being considered.

How do we store the information?

Information is stored on our main computer, telephone call recording, on paper and electronically. All such storage complies with the NHS requirements on records management. The Trust uses an archive company to store paper records off site.

Clinical Audit, Patient Surveys and Research programmes

Clinical Audit: The Trust undertakes clinical audit at a number of levels – nationally, internally and by staff locally. Each programme is governed under tight guidance both by the Trust’s Ethics Advisory Group and by the Integrated Governance Committee – all results published are fully annonymised

Patient Surveys: The Trust lays great store by the information patients provide about the services provided. While many survey questionnaires are sent out from the addresses provide by the main computer on a random basis there are some surveys which are much more focused and will have required the Trust staff to have accessed the patient record to identify particular groups of patients.

All questionnaires that are returned are destroyed on completion of the survey and the publication of the results. These are always annonymised. The Trust Ethics Advisory Group consider all questionnaires as well as the actual survey.

Research: the Trust has a research governance policy and abides by best practice. Patient details are never passed onto third parties for research purposes. Patients are only entered into any research programme if the Trust has received express written permission from the patient and that al the requirements making up research governance are completed and observed.

How can patients access their records?

Patients have a right of access to health information about themselves. The Department of Health has set down guidance on the processes to access both living and deceased patient information.

A written request by the patient is required and a copy of the record will be provided. There may be a charge made for this function.

The Department of Heath document sets down how patient records can be accessed in a variety of settings by those who have lawful access to them.