How your records are used

 Your records are used to guide healthcare professionals in the care you receive.  Your records:

  • help inform the decisions that we make about your care;
  • ensure that your treatment is safe and effective, including any advice that may be provided as part of your care;
  • help us to work effectively with other organisations who may also be involved in your care;
  • help us to thoroughly investigate any feedback or concerns you may have about contact with our services;
  • may also be available if you see another doctor, or are referred to a specialist or another part of the NHS or health care system for the purposes of direct care;
  • help us to investigate complaints, legal claims and untoward events;
  • help us to prepare statistics on NHS performance;
  • assist with health research and development;
  • help us to teach, train and monitor staff and their work (including providing staff and clinicians with anonymous feedback from patient surveys) to audit and improve our services and ensure they meet your needs
  • help us to conduct clinical audit to ensure we are providing a safe, high quality service; and
  • help us to support the provision of care by other healthcare professionals.

Using information for purposes other than direct healthcare

Healthcare organisations, such as your GP or the hospital that you visit, hold information about you in order to support the treatment that is provided. There are measures outlined in law which protect the information that is held by these organisations. These measures ensure that information is only shared appropriately and in line with your wishes.

Organisations will use this information to support you with any treatment or contact that you may have, which is known as for direct care purposes. It helps them provide the most appropriate care for you as an individual and they may share information with other health professionals to ensure that they can make informed decisions. Where this information is shared, your confidentiality and privacy will be protected. To make sure this takes place, there are clear rules in our own procedures as well as national legislation.

As well as this information supporting your care, reports are produced which contain information to help plan future healthcare services, which is termed as for non-direct care purposes. This information is used to identify areas where our services need to expand, to improve & to change, in order to support our population fully and also to support the flow of funding from one NHS organisation to another. There are clear processes in place to say how this information can be used and what safeguards must be in place to protect patients.  The ways in which information should be made anonymous are governed by the Department of Health.

The Trust uses three different types of information:

  1. Person confidential data – information which on its own or with other information can identify you.
  2. Anonymised data – where unique identifiers such as your name and full address have been removed so the information is no longer ‘person identifiable’. 
  3. Pseudonymised data – where personal information about you is replaced with a code. We retain the key to the code so would know which person this information related to but a third party who we shared this data with would not. This is often used when information is needed for research purposes or when we create our patient surveys.

Where possible, we ensure your information is anonymised or pseudonymised (especially when using information for purposes other than for direct patient care).

For all other uses of your personal information we will either directly ask for your consent or, used anonymised data that does not identify you. For example, it may be that we use anonymised and/or pseudonymised data for:

  • processing information – changing information so it can be used for secondary purposes;
  • research;
  • local and national benchmarking;
  • audits - including local clinical audit to provide quality assurance of the care received by our service users;
  • service management;
  • commissioning and commissioners reports (e.g. to Clinical Commissioning Groups CCGs);
  • contract monitoring;
  • capacity and demand planning;
  • reporting, including public health alerts, performance and board reports 
  • teaching and training; 
  • sharing best practice/serious case reviews/incident management of adverse events;
  • staff and patient surveys;
  • personal development/review (particularly for clinicians);
  • subject access requests; and  
  • risk stratification.