If you work in the NHS, all reports, results etc are covered by a confidentiality clause. Disclose anything, it's a sackable offence.
Equality and Diversity Laws, should these be scrapped??
Disappearing contributors - part 2
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Morning all.
I've recently got full access to my medical notes and was a bit shocked to find that there is a full transcript of my counselling sessions from many years ago. I'm due to see a counsellor again and it's put me off a bit. I'm a very private person and didnt realise the full chapter and verse would show on my notes.
If anyone has worked for a GP do you know who can see these notes, can a doctors receptionist for example? I think it was more a shock to me to see my feelings laid bare for myself to read if that makes sense. But I'd like to think it was between the counsellor and me.
Thanks for reading
If you work in the NHS, all reports, results etc are covered by a confidentiality clause. Disclose anything, it's a sackable offence.
Sharina
I sympathise. I worked for many years as a gp receptionist and my records were blocked. You can ask for this. I also had counselling so would be uncomfortable with my colleagues reading my notes. So ask for your records to be blocked. It’s a pain btw as it limits access and therefore help that people can give you. Also, I’m sure the majority of receptionists do not have the time or inclination to snoop. We’re all patients and tend to respect people’s privacy. I don’t recall anyone snooping in the years I worked there. Not only too busy but also aware that there are tracers on the records and you can tell if someone has been in who shouldn’t be.
Ahh thanks sharina really useful to know
lilypollen
It used to be that what was said in the Dr's surgery stayed within the four walls. Alas no longer, change for the worse and not the better and shocking the practitioners who can see them. Mind you the dentist demands to know a lot on their questionnaire. Just fill my *** tooth!
It was never true, whatever used to be said.
I sympathise. I worked for many years as a gp receptionist and my records were blocked. You can ask for this. I also had counselling so would be uncomfortable with my colleagues reading my notes. So ask for your records to be blocked. It’s a pain btw as it limits access and therefore help that people can give you. Also, I’m sure the majority of receptionists do not have the time or inclination to snoop. We’re all patients and tend to respect people’s privacy. I don’t recall anyone snooping in the years I worked there. Not only too busy but also aware that there are tracers on the records and you can tell if someone has been in who shouldn’t be.
Thanks all, really useful comments 😊
Practice are now switching on access to patient records over the next few months, they have to do this by law, it sounds as though yours has already switched it on. There are issues to be worked through, for example if details of third parties are recorded in your record.
As far as who can see your record, anyone with access to the clinical system could see it, but it would be a sackable offence unless it was needed as part of your care. For example if you ask if a prescription has been done, the receptionist would go into your last entry on your record to check that out.
I think there is a possibility, at least there used to be, of 'sealing' your record so that only your GP and you can view it. This was used for GP's families registered at the surgery, who obviously didn't want any staff accessing their record. But to get that done you should make an appointment with the practice manager.
Most GP surgeries are now sharing their data with ICNs (integrated care networks, which took over from PCTs) The data is collected into one big database which is used by GPs for out of hours care, but also for admin and accounting purposes by the admin staff.
If you have concerns and don't want your data shared into the wider network, then it depends on which clinical system your practice is using. I am not going to cut and paste a large amount of data, but if you are interested, this document would help?
www.bma.org.uk/media/1366/bma-principles-for-sharing-and-accessing-local-shared-electronic-patient-records-2.pdf
I think if you do not want your counselling records shared, then tell your counsellor to keep them private, and not send to your surgery. You could also ask for a copy of anything s/he proposes to send in summary as a check. The hospice counsellors I now work with always ask for permission to share data with the GP, and will respect refusals.
The vast majority of NHS staff are acutely aware of the need for information governance, they have to receive regular training, and are aware of the consequences of unauthorised access.
Having said that, the human brain is a very curious creature, and when Richard Hammond from Top Gear had his terrible car crash in Yorkshire, a survey of access to his hospital records revealed 400 members of hospital staff had had a look, including from the Obs and Gynae department! They were disciplined...
coco I worked as a counsellor/CBT therapist in private practice and also in primary care where I saw patients in the GP practice and at our office base. The scheme began long before IAPT and was adapted to fit when IAPT was introduced. Referrals came from the GP’s with patient agreement. The Trust I worked for was clear, no details of sessions were shared with a GP or put in patient notes unless a serious risk had been identified. Each patient was given an information sheet outlining the ‘terms and conditions’ at the beginning of the first session, an opportunity was given to ask questions and clarify, if the patient wasn’t happy they simply opted out. It was made clear should a discussion with a GP be deemed necessary the patient would always know in advance.
It was necessary to enter into patient notes that they had met with a primary care practitioner and a few words about focus, eg work related stress or sleep disturbance. Other notes were the practitioners, kept under lock and key and not shared - ever - with a GP.
I’m frankly horrified issues you took to counselling were described in any detail in GP records. I totally agree with goldenage, ask the counsellor before sharing anything what records are kept and who can access them. I would suggest it is totally reasonable to ask for time to think through the answer and to discuss concerns with the counsellor. I would also agree that a professional directory is a good place to begin to search for a private therapist.
Confidentiality was taken very seriously. Computerised records showed who had accessed them and when, inappropriate access was a disciplinary/dismissal issue. Yes, taken very seriously.
Wishing you well.
Sounds like it's taken seriously then
Accessing anybody's notes without a proper reason is a very serious offence and everyone who works in the NHS is told in no uncertain terms that anyone discovered doing so will be dismissed. I volunteer at our local hospital and sometimes have to access records of people I know but I would never breathe a word of this. On one occasion I was booking an ambulance for a patient and there was another volunteer having a cup of coffee in the office and even though I didn't mention the patient's name I was told I should have asked her to leave the office while I booked the transport because she didn't work in admin.
GoldenAge
Coco12 - I’m a psychotherapist - private practice and working also voluntarily in an NHS setting. First of all your sessions should not be recorded which means that no verbatim version should ever be available. Secondly the counsellor will have made some notes and then possibly expanded them to create some sort of record but it couldn’t possibly be word for word. Thirdly those records are supposed to be confidential. I would suggest that at your first session you ask the questions - what does the counsellor do with anything s/he writes about you and who has access and why. You’re perfectly entitled to have these questions answered and if you’re not happy and you want counselling think about going privately because counsellors in private practice must abide by the code of ethics of their professional body and that includes safeguarding personal information. In my case I write notes after each client on a computer that only I have access to and nobody at all sees them. Nor can I be compelled to reveal them except in very rare circumstances by a court. I’m sorry you found a transcript of previous counselling - this must have brought back some difficult memories. Something else to consider is that trainee counsellors are often involved in the counselling provided by GP surgeries and you might feel you want someone qualified Go to the BACP Counselling Directory or the Psychology Today Directory for some ideas
Goldenage just wondering do you send a summary to the surgery for your NHS patients?
grandtanteJE65
Medical records, tax papers and other legal papers are confidential, so no, we do not have to hope that those who read them in the course of their work are discreet.
They have signed confidentiality clauses and can be fined and dismissed from their jobs if they tell anyone what they have read or heard about any of us in the course of their jobs.
I realise this probably does not console you very much, but you are certainly justified in asking a new therapist whether everything you tell her goes into notes that any health professional can read. Perhaps you and she can address the issue of why most of us feel more embarrassed by emotional problems we have sought professional help for than physical ones.
Would the thought of health professionals reading full notes on a gynaecological or orthopaedic problem worry you so much?
You felt you had a problem and sought help for it - that is something to be proud of, not ashamed of, after all.
You're quite right, I wouldn't care as much about a physical problem.
I will definitely be looking into it more before my next sessions.
Coco12 - I’m a psychotherapist - private practice and working also voluntarily in an NHS setting. First of all your sessions should not be recorded which means that no verbatim version should ever be available. Secondly the counsellor will have made some notes and then possibly expanded them to create some sort of record but it couldn’t possibly be word for word. Thirdly those records are supposed to be confidential. I would suggest that at your first session you ask the questions - what does the counsellor do with anything s/he writes about you and who has access and why. You’re perfectly entitled to have these questions answered and if you’re not happy and you want counselling think about going privately because counsellors in private practice must abide by the code of ethics of their professional body and that includes safeguarding personal information. In my case I write notes after each client on a computer that only I have access to and nobody at all sees them. Nor can I be compelled to reveal them except in very rare circumstances by a court. I’m sorry you found a transcript of previous counselling - this must have brought back some difficult memories. Something else to consider is that trainee counsellors are often involved in the counselling provided by GP surgeries and you might feel you want someone qualified Go to the BACP Counselling Directory or the Psychology Today Directory for some ideas
I've previously completed a form for records not to be shared, it was when things first went onto an electronic system. My concerns were that the info was mine and I didn't want it sold or shared without my permission. I'm not sure if that still holds because I've found services outside of my GP who could find out a few things about me, quite limited though, I think there are summary records apart from the full ones. The problem with too much information about you is that if you can get labelled with something and if it's immediately available to the next doctor who sees you they may make assumptions and not look beyond it. I'm a carer, which you would think was a good thing to have on your records but no, some GPs have been very dismissive and treated me as if I'm stressed and anxious and looking for support rather than ill and looking for medical care. Personally, I would ask your GP manager to tell you who the ' 'confidential' counseling notes are available to, and possibly have them removed from view. I would not expect counseling notes to be available as you were probably told it would be confidential - unless there was something that suggested a risk to life. I think this might even be a breach of professional conduct to be honest. My friend is a professional counselor and holds her notes for a limited amount of time after its finished and then destroys them. They are not shared, not even a summarised version.
watermeadow
At one time we were handed our medical records to take into the GP. In the waiting room, after glancing through, I realised I’d been given the records of someone else with the same common name. Another time I found that my young child’s records included entries for a sibling and for a middle aged man!
watermeadow When I phoned and spoke to a receptionist several years ago I was puzzled when she mentioned a medication she insisted I was on, which I knew I was not. I asked for my notes and it turned out there was another patient with the same name and many of her records were mixed up with mine including her operations and medication. The GP (now retired) promised to sort it all out.
However, recently I picked up a repeat prescription from the chemist and received hers as well as my own.
My husband's GP was closing his practice and returned his patient notes to him with no warning. He was upset to see comments of surgeon who performed difficult operation which were intended for the GP's eyes only. Surely there is a need for a confidential section for the professionals to exchange information?
Medical records, tax papers and other legal papers are confidential, so no, we do not have to hope that those who read them in the course of their work are discreet.
They have signed confidentiality clauses and can be fined and dismissed from their jobs if they tell anyone what they have read or heard about any of us in the course of their jobs.
I realise this probably does not console you very much, but you are certainly justified in asking a new therapist whether everything you tell her goes into notes that any health professional can read. Perhaps you and she can address the issue of why most of us feel more embarrassed by emotional problems we have sought professional help for than physical ones.
Would the thought of health professionals reading full notes on a gynaecological or orthopaedic problem worry you so much?
You felt you had a problem and sought help for it - that is something to be proud of, not ashamed of, after all.
A lot of surgeries no longer hold the Lloyd George notes (buff coloured envelopes) on site. They're kept elsewhere depending on which part of the country you live.
Any piece of paper ascertaining to you, the patient, will be scanned onto your notes. This means anyone that has log-in access to your screen, inc receptionists, nurses, Health Care Assistants etc etc, can read your scanned on notes.
When I worked on GP'S Recep 8 years ago a patient could pay to see their medical record.
At one time we were handed our medical records to take into the GP. In the waiting room, after glancing through, I realised I’d been given the records of someone else with the same common name. Another time I found that my young child’s records included entries for a sibling and for a middle aged man!
Yes you can only hope they are true to their obligations of confidentiality.
It used to be that what was said in the Dr's surgery stayed within the four walls. Alas no longer, change for the worse and not the better and shocking the practitioners who can see them. Mind you the dentist demands to know a lot on their questionnaire. Just fill my *** tooth!
If the GP requested the original counselling via the NHS they will get a full report back.
It's a stackable offence to share that confidentiality outside of the professional capacity.
However you are always entitled to a copy of the letter being sent to the GP just ask the Doctor or Therapist to send you a copy.
Done frequently where I work, so patients fully aware of the plan.
As a student social worker I spent some time helping an individual to come to terms with her complex grief over the death of her sister. I was required to produce detailed notes for my assessment an had made her aware of this. I went through my recording at the last meeting we had. She said she found the sessions beneficial and that reviewing the process via the notes had also been very useful but did not want them kept on record. I agreed with my practice teacher that I would put a brief summary on the notes that counseling sessions had been held including the individual's comments which she said was fine with her. This was in 1986(!) and based on the practice of Priestley and Maguire - 2 probation officers whose work I admired.
All that private information! 😕
A receptionist was sacked at our GP surgery a couple of years ago because she accessed patients records of hundreds of people who she knew, friends, neighbours, relatives etc. her excuse was she did it when she had nothing else to do.
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