Appendix 4

Disclosure Team

Medical Records

St Nicholas Hospital

Jubilee Road

Gosforth

Newcastle upon Tyne

NE3 3XT

Tel: 0191 2466891

e-mail –

Draft letter/template, guidance and clinical response form to be provided to appropriate health care professionals for SAR/DPA

RC/AHCP

Dear

RE: Access to Records – Data Protection Act 1998

Name: ……………………………………………………Date of Birth: ……………………………

NHS No: …………………… RiO/IAPTUS No: ………..…..... Safeguard No: …………………

Date request made ...XX/XX/XXXX…. Request deadline ……XX/XX/.XXXX………….

Date for return of records to DisclosureTeam : …………XX/XX/XXXX………..

The above named patient has requested access to his/her Health Records and the Trust has a legal duty to respond to this in accordance with the above dates; you have been identified as the Appropriate Healthcare Professional to facilitate the disclosure of this information.

I have enclosed a clinical response form and some helpful guidance for your use in relation to this request. Once you have made your assessment of risk and complexities of this case please contact the Disclosure Team to enable us to record this information onto the Trust’s Safeguard system to assist in the progression of the request.

Please refer to the guidance overleaf and if you feel that this request meets the criteria for a complex request, please inform the disclosure team as soon as possible so that the requirement for additional support can be assessed to ensure the response can be made within the required timeframe,

Appropriate access will be agreed based on your clinical judgment. Under the terms of the Act you do not need to consult with any other clinicians involved in the care of the patient, your assessment is sufficient.

Within the terms of the Act (requestors name) must receive a formal response from the Trust within 40 days. Therefore I require a response and the record(s) be returned by (date).

Information may only be restricted in the following circumstances:

  1. The release of information is likely to cause serious harm to the physical or mental health of the patient or other individuals.
  2. Would identify an individual other than the patient or health professionals involved in the delivery of care and treatment, who has not given permission for information to be released.
  3. In the case of a child or a patient who is incapable of managing their own affairs or a patient who has since died, access cannot be given to information which the patient gave in the expectation that it would not be disclosed or information obtained as a result of any examination or investigation to which the patient consented in the expectation that the information would not be disclosed.
  4. In the case of an applicant who has a claim arising out of the patient’s death access can be given to that part of the record, which is relevant to the claim.
  5. Where the patient has died, access cannot be given if the record included a note made at the patient’s request, that access should not be given.

In the case of a child, an application for access to health records can be made by the parent or person having parental responsibility, the parent can only do this with the child’s consent. If the child is incapable of understanding the nature of the application, if access would be in his/her best interest the record holder can give access.

If you have any legal queries regarding the request for access, please inform the team for onward referral to the Trust’s Caldicott Guardian and/or Solicitors.

Yours sincerely

Disclosure Team

Encs

ACCESS TO HEALTH RECORDS

CLINICAL ASSESSMENT RESPONSE

Having reviewed the Health Records of: RE:DOB:

I can confirm that:

(Please circle the appropriate number)

  1. Full access can be given
  2. I have identified third party information that must be removed prior to disclosure. (please mark pages with post-it notes)
  3. *I have identified information that if disclosed, would cause serious harm to the physical or mental health to the above named or others. (please mark pages with post-it notes)

*Please state reasons for non-disclosure below:-

Date of entry / Description (e.g. whole document, page, paragraph, sentence, word) / Reason for non-disclosure

Signed: ……………………………………………Date: ………………………….

Please Print Name: ………………………….………………………………………….....

Guidance for Appropriate Healthcare Professionals when a patient asks for Access to their Health Records

Patients have a legal right to request access to their records and the Trust must respond to this request and provide relevant information within 40 working days.

When a patient asks to see their health records, an Appropriate Health Care Professional (AHCP) must be involved in the process of facilitating that access, specific decisions about disclosure must be made by an Appropriate Health Care Professional. This is the person currently or most recently responsible for the clinical care of the patient as identified on the relevant clinical information system. If the patient is currently seen by a multi-disciplinary team, then discussions may be held within that team regarding the disclosure of information, but the identified AHCP is responsible for overseeing the completion of the request.

The AHCP will be provided with all original health records and the printed copies of records from the RiO/IAPTus system by the disclosure team.

When checking the records for information which may need to be redacted the following piece of legislation should be adhered to:

The Data Protection (Subject Access Modification) (Health) Order 2000 enables the data controller (for clarity this is the AHCP) to limit or deny access to an individual’s health record where:

  • The information released may cause serious harm to the physical or mental health or condition of the patient, or any other person, or
  • Access would disclose information relating to or provided by a third person who has not consented to the disclosure unless:
  • The third party is a health professional who has been involved in the care of the Patient
  • The third party, who is not a health professional, gives their consent to the

disclosure of that information

  • Is it reasonable to disclose without that third party’s consent

The AHCP must check all records and be aware of the risks and complexities each request may contain. This may be by personal knowledge of the applicant, information from team members, past history and so on. AHCPs are encouraged to seek help and guidance when carrying out the redaction process from the Disclosure Team. All are easily contactable via the switchboard during office hours.

Serious Harm

The AHCP/multi-disciplinary team should consider the following:

  • Whether there may very well be a risk of harm to health even if the risk falls short of being more probable than not.
  • What constitutes serious harm to the requestor based on the known information about the individual and recorded information in the record.
  • Known risks on CPA/FACE documentation. alerts on RiO record.
  • Carer’s assessment/carer’s care plan to be removed if applicable.
  • There is evidence that clinical records have been withheld in the past and the reasons why this decision was taken stated.
  • Consideration has been given as to the patient’s known current mental state and whether the request for the information is linked.

Once information has been identified for redaction then it should be clearly identified on the clinical response form, as to what needs to be removed and the rationale given.

The responsible clinician should make an entry into the patient’s health records to explain the redaction of the information and the rationale.

Examples of risk of serious harm

  • Patient has known alert indicators on care plan/risk assessment that state is paranoid about particular family members.
  • Entry in notes state that family member has reported recent serious incident involving patient.
  • Entry may be redacted to prevent repercussions against family members and reinforcement of paranoia.

Third party Information

Third party information provided by individuals who are not health professionals involved in the case and whose permission would be needed to disclose to the requestor.

It is the responsibility of the AHCP and multi-disciplinary team to identify information provided by third parties for redaction.

1

Northumberland, Tyne and Wear NHS Foundation Trust

RM-PGN-05 – Appendix 4 – Letter, Clinical Response Form and Guidance for AHCP Form – V03 – Iss 2 Sep 17

Part of NTW (O) 09 Management of Records Policy