Understanding Your Medical Record
When reading your medical record online, you may come across some abbreviations and terminology you are not familiar with. For example, "SOB" is sometimes written in a patient's notes to describe "Shortness of Breath" and "CXR" for Chest X-ray.
The quickest way to find out what these mean is to visit the below websites, which contain lots of medical abbrievations and their explanations.
Accessing your GP-held records via the NHS app or NHS website
As your GP practice, we have been asked to provide you with, no later than 31 October 2023, access to your full medical record going forward via the NHS app (and NHS website) if you have a suitable NHS login
Your GP medical record contains consultation notes based on conversations between you, your GP and their team: medicines prescribed to you; all test results including hospital investigations; allergies; vaccines; and your medical conditions along with documents that may have been sent from local hospitals, clinics or other agencies, eg the police. There is likely to be sensitive and personal information within your medical record.
We are supportive of providing you with access to your record, but we wish to do this safely and make you aware that this is happening so that you can opt out, if you so wish. You may wish to speak with us first to understand what it is that you will see, and the risks which may be involved in having such confidential data either on your smartphone with the NHS app installed or online if other people might have access to that information through your devices. If you are in a difficult or pressured relationship for example, you may prefer your records to remain accessible only to those treating you, with them not appearing on your smartphone or online. Government has been clear that if a patient does not wish to have access, then we do not have to provide it. This is one reason why we have asked if you wish to opt out, or have it switched off for the time being.
For those who would like access, we are happy to explain the different levels you might like. Everyone can have access to their medication history and allergies, for example, and will be able to order their repeat prescriptions. It’s also possible to request access to what we call your ‘coded record’ where you can see a list of medical problems and results. You can also request access to the ‘full’ record where you will be able to see everything prospectively, including the notes which have been written by doctors, nurses and others involved in your care, at the GP surgery, and elsewhere.
It’s important to remember that these documents may, at times, contain information that could be upsetting, especially if they contain news of a serious condition. It can also be a cause for worry seeing results online when it isn’t clear what the results might mean, and no one is available to ask, as can be the case during the evening or at weekends, for example.
Sometimes people with a mental health condition might prefer not to see documents that remind them of difficult times in their life. Letters from mental health teams sometimes go into detail about past events, and great care would be needed in deciding whether you would want to see these letters. It is possible for individual items to be hidden at your request and your GP would be happy to talk about any concerns you may have.
Great care is also needed in case private details might cause harm at home, should people in a difficult or pressured relationship be forced to show their medical record to an abusive partner. Anyone in such a position should make this clear to us at the practice, so we can take steps to keep you safe. This might mean removing access through the NHS app for the time being, or through a careful process where we hide sensitive things. We would talk this through with you.
Requesting access – what do I need to do?
The easiest way to get access is to create an NHS login through the NHS app. Although you can also access your GP records via the internet on a computer, the first bit is easiest if done through a smartphone. You can ask us, but you’ll need some proof of who you are, eg a passport, driving licence or household bill.
If you use the NHS app, you’ll have to set up an account using a unique e-mail address and then ‘authenticate’ yourself to the NHS system to prove you are who you say you are. This will involve confirming your name, date of birth and contact details. The NHS login has several levels of authentication and to gain access to your records you’ll need the highest level of authentication. This generally involves you recording a short video of yourself to prove you are a real person as well as uploading a copy of a suitable identification document. Your GP practice can bypass this step if you are struggling, but we’d ask you to try to sign up to the NHS app yourself.
Once you have suitably authenticated yourself to the NHS app and created your NHS login you can approach your practice and ask for access (access form found below), being mindful of the risks associated with access and the importance of not sharing passwords or having them stored in your smartphone if you think other people might want to see them without your permission. If you have any concerns, you should explain these to your GP practice team who can guide you.
Your GP practice will have a form they will ask you to complete (see below), with your NHS login (this will be the email address you used to sign up) and then you will have a chat about access and your agreement and understanding will be requested. Once you are happy to get online access, your request will be passed to the clinical team to review. It may be that the practice wishes to contact you to discuss your request if there are any concerns raised so that access can be given safely. We’re not sure how many people will ask for access all at once so there may be a wait, but we will do our best to get you online access as soon as we can.
Acceptable Forms of ID
- UK Citizens ID card of connexions card
- Driving Licence
These have to be in date and have correct name, date of birth and address on (if applicable).
If no photo ID is available then 4 forms of ID from below.
Non-Photographic confirmation of address
- Birth certificate
- Driving licence
- Utility bill
- Council tax statement
- HMRC tax notification
- Bank, building society or credit card statement.
- Credit union statement
- Mortgage statement
- Council rent statement
- Benefit statement
- Work/residency permit
- Adoption certificate
- Marriage or civil partnership certificate
- Gender recognition certificate
- Firearms/shotgun certificate/licence
- Police registration document
- HM forces certificate of employment
- LOCAL government document – ie jobe centre or employment services
- Grant or student loan agreement
- National insurance card
- Letter from head teacher/tutor /college on official paper stating patients name address and date of birth
If a bill or statement is accepted it must be dated within the last 3 months.
Online Services Security
- It will be your responsibility to keep your login details and password safe and secure. If you know or suspect that your record has been accessed by someone that you have not agreed should see it, then you should change your password immediately. Access can also be gained on some phones using fingerprints or Face ID – please consider this.
- If you have concerns about this, we recommend that you contact the practice so that they can remove online access until you are able to reset your password.
- If you print out any information from your record, it is also your responsibility to keep this secure. If you are at all worried about keeping printed copies safe, we recommend that you do not make copies at all.
- The practice may not be able to offer online access due to a number of reasons such as concerns that it could cause harm to physical or mental health or where there is reference to third parties. The practice has the right to remove online access to services for anyone they feel it could harm or be put at risk.
There may be something you have forgotten about in your record that you might find upsetting.
Abnormal results or bad news
If your GP has given you access to test results or letters, you may see something that you find upsetting to you. This may occur before you have spoken to your doctor or while the surgery is closed and you cannot contact them.
Choosing to share your information with someone
It’s up to you whether or not you share your information with others – perhaps family members or carers. It’s your choice, but also your responsibility to keep the information safe and secure.
If you think you may be pressured into revealing details from your patient record to someone else against your will, it is best that you do not register for access at this time.
Your medical record is designed to be used by clinical professionals to ensure that you receive the best possible care. Some of the information within your medical record may be highly technical, written by specialists and not easily understood. If you require further clarification, please contact the surgery for a clearer explanation.
Information about someone else
If you spot something in the record that is not about you or notice any other errors, please log out of the system immediately and contact the practice as soon as possible.
We can consider application from patients under the age of 16, or those who require proxy access e.g. carer or spouse. However, to avoid coercion and to protect data, we will require consent from the patient to make sure they agree to you having access to their record. If you are a parent/carer who would like access to just booking appointments and ordering medication for under 11 year olds, this can be done through your own SystmOnline account. Please speak to a member of the reception team to set this up.
We reserve the right to refuse access if we are unable to verify your identification or in the case of proxy access, if we are unable to confirm that the patient has given their consent to share their record with you.
When your details have been verified we can issue a password and access to SystmOnline via our website at www.coleridgemedicalcentre.co.uk At first log in you will be asked to change your password.
PLEASE NOTE - if you would like to apply for Proxy Access, you must attend the surgery to fill out the form. You must also bring two forms of valid ID for yourself in order to proceed. If you are applying for Proxy Access for your child, please also bring a copy of their birth certificate.