Document Control:

Version 2

Ratified by Clinical Policies Review and Approval Group

Date Ratified 5 November 2019 (Amendment)

Name of Originator/ Author

Associate Nurse Director, North Lincolnshire Care Group

Name of Responsible Committee/Individual

Clinical Policies Review and Approval Group

Unique Reference Number:

473

Date issued 26 November 2019

Review Date October 2021

Target Audience All staff with responsibility for clinical record keeping

Healthcare Record Keeping Policy

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CONTENTS

Section Page

1. Introduction 3

2. Purpose 3

3. Scope 4

4. Responsibilities, Accountabilities and Duties 4

5. Procedure 6

5.1 Healthcare Record Keeping Standards and Guidance 6

5.2 Electronic Records 7

5.3 Paper Healthcare Records 8

5.4

5.5

5.6

5.7

Security and Access

Tracking of Paper Healthcare Records

Retention and Disposal of Healthcare Records

Copying letters to Patients

10

10

11

11

6. Training Implications 12

7. Monitoring Arrangements 13

8. Equality Impact Assessment Screening 14

8.1 Privacy, Dignity and Respect 14

8.2 Mental Capacity Act 14

9. Links To Any Associated Documents 14

10. References 15

11. Appendices 16

Appendix 1 - Copying letters to patients flowchart

Appendix 2 - Copying letters to patients information leaflet

17

18

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1. INTRODUCTION

Information is the lifeblood of any NHS organisation – essential to the delivery of high quality evidence based health care and administrative support functions on a day-to-day basis.

The Chief Executive and Senior Managers of the Trust are accountable for the quality of the healthcare records that are generated by staff working in the Trust which supports patient safety and quality service delivery.

Rotherham Doncaster and South Humber NHS Foundation Trust (The Trust) needs to ensure that all healthcare records are created, accessed, managed and disposed of in accordance with national standards and professional accountability; and are compliant with legal, operational and information governance requirements

The Trust must conform to a number of legislative requirements, regulations and

standards (see references) that outlines the management of records. These can also be found in the Trust’s ‘Record Management’ policy.

Healthcare records are an integral part of healthcare practice which is generated

on, or on behalf of, all the health professionals involved in all aspects of patient care (e.g. the care, service and treatment provided).

The primary function of healthcare records is to record healthcare information,

which may need to be accessed by the various professionals delivering healthcare. Whilst it is not a legal requirement, it is the patients right to be offered the

opportunity to receive a copy of any letters written by one professional to another. The general principle is that all letters which help to improve a patient’s understanding of their health and the care they are receiving should be copied to them as a right. This is supported as good practice by the GMC (General Medical Council), RCPsych (Royal College of Psychiatrists) and the Department of Health 2003 (refer to Appendix A for process).

Healthcare records are generated in a variety of ways including electronic patient record, paper and media storage (such as DVD).

Patients have the right to request/receive information held about them under the Data Protection Act 1998 and the Freedom of Information Act 2000. In addition, the NHS Plan (2000) paragraph 10.3, made a commitment that patients should also be able to receive clinicians letters about them as a right. This means that if patients, consent/agree, letters written by one health professional to another about the patient should be copied to the patient, or where appropriate, parent or legal guardian.

2. PURPOSE The overall aim of this policy is to ensure that the healthcare records generated by

all health professional within the Trust are contemporaneous, up to date and an accurate account of patient care/care delivery. In doing so, they contribute to the achievement of the Trust’s Vision, Mission, Values and Strategic Objectives: https://www.rdash.nhs.uk/about-us/overview/our-vision-and-values/

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This policy will support staff that generate healthcare records to ensure that record keeping is of a high standard and supports the delivery of evidence based practice and high quality care.

This policy will facilitate the communication to all Trust employees of their roles and responsibilities and accountabilities in complying with guidance, legislation and best practice for keeping records.

This policy should direct clinicians towards the procedure for copying letters to patients or their nominated recipient.

3. SCOPE

This policy covers all healthcare records held, used or managed in all formats in use by the Trust.

This policy will apply to:

All employees working for or on behalf of the Trust. People who are not directly employed by the Trust but contribute to and support care delivery and generate healthcare records including contracted third parties, agency staff, locums, students/trainees, secondees, staff from partner organisations with approved access, visiting professionals, researchers, companies providing other services to the Trust e.g. IT and all volunteers.

Any Trust healthcare records held, maintained and managed by third parties under contract to the Trust.

4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES

The Trust has a ‘duty of care’ and a ’duty of confidentiality’ to ensure that all aspects of healthcare record keeping are properly managed. The Trust must adhere to the legislative, statutory and good practice guidance requirements relating to healthcare records management. In order to meet these requirements and demonstrate effective healthcare record keeping management, it is necessary to have a clear operational policy.

The Chief Executive has overall accountability and responsibility for healthcare

records within the Trust and this function is delegated to the Executive Medical Director and the Executive Director of Nursing and Quality, who will be responsible for driving high quality standards of healthcare record keeping.

The Trust’s Executive Medical Director (and Trust Caldicott Guardian) plays a

key role in ensuring that NHS and partner organisations comply with extant national guidance and relevant legislation in regard to the handling and safeguarding of ‘Patient Identifiable Information’ The Guardian will advise staff on matters relating to the management of patient identifiable information, for example where issues such as the public interest conflicts with duties such as the maintenance of confidentiality.

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Senior Managers of the Trust are responsible for the quality of the healthcare records that are generated by staff working in the Trust to ensure patient safety and quality service delivery.

The Deputy Director of Business Intelligence and Information will advise the

Trust on how to maintain an efficient and effective patient information system, which complies with all the data collections required within the NHS.

The Clinical Audit Team will lead on the annual Trust Health Records audits, as

part of the annual clinical audit work programme; liaising with identified audit leads within each team/service area and using an audit tool in accordance with ‘Healthcare Record Keeping Standards’. The results of the audit are reported through the Trust’s governance structures for quality.

All employees of the Trust are responsible for any records which they create or

use. This responsibility is established at, and defined by, the Public Records Act 1958. As an employee of the NHS, any records created by an employee are public records. All individuals must adhere to all of the Trust’s record keeping and records management policies. In addition, all clinical staff have a professional responsibility and accountability to comply with record keeping standards and protocols specific to their professional Codes of Conduct/Practice e.g. Nursing and Midwifery Council (NMC) Record Keeping: Guidance for Nurses and Midwives 2009 and General Medical Council (GMC) Good Medical Practice: Guidance for Doctors.

It is the responsibility of clinicians to make patients aware of the fact that they are entitled to receive copies of any letters or documents which relates to them. If the patient expresses a wish to receive copies the individual business division clinician must document this in the patient’s health records. For patients who do not wish to receive copies an entry to this effect will also be made in their health records.

For any patients who express a wish not to receive copy letters, the lead clinician involved in their care will be responsible for reviewing their decision with them at each formal review or when the clinician or patient deems it to be appropriate.

Whenever a letter has been shared and also when they have not been shared, the clinician is to document this in the patient’s health record. If a decision is made not to share the information the clinician must be able to justify this decision.

Person responsible for generating letters to patients (Lead Professional,

Healthcare Professional/Clinician) It is the responsibility of the person writing or dictating the letter to ascertain and

record in the patient’s health records:

whether the patient wants to receive a copy letter

how they wish to receive it

the address to send it to

in what format

in the case of children, who has parental responsibility

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arrange with a designated person/member of the administrative staff for this to take place

The patient will need to make an informed decision to consent/ withhold consent on whether they wish to receive clinician’s letters. They will be given a choice on what information they want, who from, the address to which it will be sent and what format (if appropriate). If a patient does not want to receive letters, this decision will be reviewed at each formal review or when the clinician and patient deem it to be appropriate.

5. PROCEDURE 5.1 Healthcare Record Keeping Standards and Guidance The Trust’s healthcare records are primarily held on the Electronic Patient Record

(EPR) system which has safeguards in place to protect the integrity, accessibility and accuracy of the record. Where there are paper records, the healthcare professional is personally responsible and accountable for their compliance with standards.

The principles of effective healthcare record keeping are:

Accessible to all staff that require access in order to enable them to carry out their duties – information must be stored in the correct areas on the EPR and are entered via approved data entry formats where they exist.

Understandable, clear and concise – Healthcare records must avoid the use of jargon and technical terminology as the patient must be able to read and understand what is written about them. The record may also be accessed by other professionals for the purposes of healthcare delivery and they must be able to understand what is written. Abbreviations should not be used within the healthcare record. Where a health professional wishes to abbreviate anything, this should be written in full in the first instance with the abbreviation written in brackets after.

Factually accurate and relevant – Healthcare records must be a factual record of the care that is delivered and where possible, collateral evidence should be sought. The record must not contain irrelevant information or personal opinions.

Secure – When accessing records, staff must ensure that this is done using a smartcard and PIN number. Username and passwords should not be used unless there are issues with the smartcard software. Passwords and PIN numbers should not be written down or shared, and if working on non-Trust premises, staff must ensure that their computer screens cannot be seen by others. Paper records should only be used in the event of system failure and these should be scanned onto the EPR once the system is live.

The purpose of a healthcare record is to facilitate the care, treatment and support of

a particular patient. In order to ensure that healthcare records are created in a consistent and professional manner the ‘Health Care Record Keeping Standards’ should be adhered to at all times.

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The Trust is developing guidance notes in order to optimise the use of the EPR and all staff are expected to follow these as these are best practice for using the EPR.

5.2 Electronic Healthcare Records When creating an EPR for a patient, there will be a number of unique, patient

identifiable information that will be downloaded automatically from the national summary care records system (Spine) and will include:

Date of birth

Surname and forenames

Gender

Address and postcode

NHS Number In addition to this, permission must be obtained from the patient, for staff to access

the following information:

Ethnicity

Allergies/sensitivities/hypersensitivities

Medication The details above cannot be altered on the summary care record by Trust staff as

this remains the responsibility of the patient’s General Practitioner (GP). If the patient moves whilst under an episode of Trust care, the practitioner can record the new address on SystmOne as a temporary address and advise the patient’s GP surgery of the change of address.

There is a data set of information that is a mandatory requirement for all patients

who use Trust services and these are identified below:

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Following an assessment of a patient, the assessment and outcomes must be recorded on the EPR on the approved templates that have been provided.

The EPR must have the following as a minimum:

an assessment of need

a personalised plan of care which links to the assessed needs of the patient

a risk assessment and management plan Contemporaneous records of healthcare contacts/events which are recorded in the appropriate data entry template and/or questionnaire, or in the case of medical staff, in the doctors’ data entry template.

All records should be written, where possible, with the involvement of patients and/or their families to ensure that their views are reflected and that the care being offered is personalised. The NHS Plan (2000) paragraph 10.3, made a commitment that patients should also be able to receive clinician’s letters relating to their care as a right.

It is expected that where practically possible, healthcare records are updated within

24 hours of the contact to allow for contemporaneous and factual accuracy and to enable relevant information to be shared in a timely manner. All agile workers (those with remote access to Systmone via laptop) should always be expected to update certain aspects of the clinical record at the time of the visit: for example administration of medicines, specific risks associated with safety.

Where a delay in entering information has occurred, this should be clearly marked

by the health professional that the record is being entered as a retrospective entry, along with the reason for the entry being delayed.

Whilst cutting and pasting of data/information within healthcare records is not

routinely advocated; in instances where it is appropriate e.g. information from a different section of the healthcare record, the health professional must ensure that the information being placed into the record is relevant to that patient and that confidentiality is maintained. Any copied healthcare records must not consist of any information from another patient’s records e.g. care plans.

5.3 Paper Healthcare Records Whilst the majority of healthcare records generated will be held on the EPR system,

paper records are still in existence within the Trust. Paper records permissible for use and agreed by the Trust include (but are not limited to):

letters sent to the Trust from external sources

test results

paper based assessments, particularly self-rating tools

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Any paper records, such as the above, should be scanned and uploaded to the EPR using the approved methods in the ‘Scanning of Physical Documentation’ policy. Historical paper records, do not need be scanned onto the EPR, however must be stored in accordance with the Records Management Policy.

Where services are scanning on to the EPR they must ensure that they follow the

‘Scanning of Physical Documentation’ policy before any decision is taken to destroy all hard copies. Services should consult with the Records Manager if they are unsure.

Paper healthcare records should have the following:

Patient’s name, date of birth, NHS Number and any allergies/sensitivities recorded on every sheet of paper, including both sides if both are used.

A case record folder constructed of robust material to withstand handling and transport with secure anchorage to prevent loss or damage for those documents that require to be kept.

All paper records retained by the Trust should comply with the following Health Record Keeping Standards in that they should:

be available within the area/ward where the patient is being cared for

have a clear ‘alert’ on the front of the record where there are patients who have the same or similar names

where a patient has more than one set of notes this must be stated on the front cover of the file as ‘file…of …’ and a year sticker attached

a ‘File Tracker’ form should be attached to the inside front cover of every file and completed for all movements of the file in order to maintain a full audit trail

all records must be written clearly, legibly, in black permanent ink to ensure accurate photocopying and in such a manner that they can’t be erased

Electro Convulsive Therapy information is readily identifiable, if applicable

all machine produced recordings are securely stored within the healthcare record

on completion of any written text to a line, a single black line must be drawn from the last word to the margin/edge of paper to ensure no additions/ amendments can be added/made to the line

all entries must be dated, timed (using 24 hour clock) and signed with the signature being printed alongside

all entries made by non-registered health professional, for example students and apprentices, must be countersigned by a registered health professional. In addition any staff who has been assessed and identified as non-competent to make independent entries, must be countersigned by a registered health professional

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a single line must be used to cross out and cancel mistakes or errors and this should be dated and timed then signed by the person who has made the amendment. Erasers, liquid paper or any other obliterating agents must not be used

if a file has been closed the full date of closure should be recorded on the front cover of the file

Any paper healthcare records should be arranged in a logical structure and be ordered chronologically with the most recent on top. Duplicate papers should be removed and where a file becomes too large (usually no more than 3cm thick), a second volume should be created.

Section on Media Healthcare Records is required

If any clinician needs to add multimedia information to a patient’s clinical record they need to seek advice from both IG and IT to ensure that the system has the required capacity and agree in what section of the record it is to be stored.

5.4 Security and Access All staff members are responsible for the safe custody of healthcare records whilst

in their possession. Therefore, all paper healthcare records must be stored in secure areas and only accessed by authorised personnel with security code/swipe access/key access.

Healthcare records are deemed to be vital to the Trust, which means that they

would be required for business continuity in the event of a disaster. This means that all hard copy healthcare records should be adequately protected from fire, water damage, pests, theft and any other potential disaster.

Staff should refer to the policies listed in this document for further information. 5.5 Tracking of Paper Healthcare Records Tracker systems should be in place to enable staff to locate paper healthcare

records to ensure that their movements e.g. to a different location/area are traceable.

When paper healthcare records are removed from a location, a tracking system

should record:

the name and role of the individual staff member who has removed the record

patient name

NHS Number

the date of removal

new location of the record

whether permanent/temporary removal

the date it was returned N.B. where a health record cannot be found, it should be reported as an

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incident to the relevant Service Manager, Records Manager and an IR1 report completed.

5.6 Retention and Disposal of Healthcare Records

For staff guidance on the retention and disposal of healthcare records of all types, including paper, electronic and media (e.g. DVD) should be disposed of in accordance with the ‘Retention & Disposal’ policy – accessible on the Trust’s intranet. If in doubt please contact the Records Manager.

5.7 Copying letters to patients At each consultation that generates letters, or when the clinician deems it appropriate, they should ask the patient if they wish to receive a copy of that letter. The patient’s decision should be recorded in their health records. Important points for consideration in each case:

the wishes of each patient will need to be considered individually and the outcome of that consideration recorded

take into account the patient’s capacity to read, comprehend and safeguard letters, particularly for patients with cognitive impairment

patient’s consent to receive clinical letters

third party confidentiality

third party access to letters

the needs of patients with visual impairment

the needs of patients who do not have an understanding of English language

confidential information which may be detrimental to the patient

appropriate format

Consent In line with overall NHS policy of valid consent, patients will be asked at first point of contact with the service, during their initial assessment, if they would like to receive copies of letters and reports. The patient’s decision will be recorded. It is good practice to review this decision at each formal review, but as a minimum it will be reviewed no less than on an annual basis. Patients who express a wish not to receive information will also have this decision recorded and reviewed annually by their lead clinician. Where capacity is in doubt the mental capacity of each patient to receive copies of information will be determined by the professional performing the assessment. As an overarching principle capacity assumed unless otherwise indicated. This decision must be recorded contemporaneously in the notes/health record.

What constitutes a ‘letter’?

A ‘letter’ includes communications between different health professionals, social care staff and support staff; for instance those from and to GP’S, hospital doctors,

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nurses, therapists and other healthcare professionals and social care staff and support staff. Different types of letter include:

summary of care letters or referral forms generated by the trust

letters from NHS health professionals to other agencies

letters to primary care following discharge, an outpatient consultation or episode of treatment

Raw data, such as test results should not be sent, but the outcome can be included in a letter that is copied to the patient. These results should have been communicated prior to them receiving a letter and there should be no surprises in the letter that could distress the patient.

Frequency of copies Where there is frequent communication, the person responsible for writing the letter should consider if it would be useful for the patient to have a copy every time. The decision should be based on a discussion with the patient about whether receiving a copy will improve communication with them and assist them to understand their own healthcare or treatment.

When letters should not be copied There may be reasons why letters cannot be shared:

where the patients does not want a copy

where the clinician feels it may be detrimental/cause harm to the patient

where the letter includes information about a third party, who has not given permission for this use of the information

where safeguards for confidentiality may be needed On those occasions, when information in the letter might significantly impair the therapeutic process, it would be good practice to discuss the matter with fellow team members. Clinicians must make a note on letters that are not to be sent to patients and giving the reason why.

6. TRAINING IMPLICATIONS The Training Needs Analysis can be found in the Mandatory and Statutory Training

Policy on the Trust website/Publications/Policies/Corporate/Learning and Development/.

All new staff will be made aware of the existence of this policy via the induction

process and a copy will be available on the website. Managers must highlight to staff their responsibility to ensure that they review the content of this policy and the importance that the Trust places on the appropriate creation, management, retention and disposal of healthcare records.

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Managers must actively ensure that staff who create, manage, transfer, retain or dispose of healthcare records undertake appropriate training opportunities.

Training will be appropriate to the individual employee’s role, regularly assessed

and refreshed to ensure employees remain appropriately skilled and knowledgeable over time. All staff that handle, access or populate healthcare records will receive face to face healthcare record keeping training on induction to the organisation; and a 3 yearly update is required via the following Healthcare Record Keeping update resource.

7. MONITORING ARRANGEMENTS

Area for Monitoring

How Who by Reported

to Frequency

Policy

An audit of healthcare record keeping (including compliance with this policy) will take place on an annual basis Trust wide.

Clinical Audit Team

Via the Trust’s Governance structures for Quality, including outcomes and exceptions.

Annually

Staff practice standards/ competence

Assessment and management of professional competency is monitored at a local level through the following arrangements:

monthly audit of patient records by Ward Manager

via individual staff supervision/PDR processes

Ward Manager Line Manager

Care Group Governance meeting Kept with individual staff personnel records

Monthly As per Trust Policies

Any complaints which are received in relation to copy letter requests

Quarterly complaints analysis

Service Managers/ Matrons in conjunction with the Complaints Manager

The relevant Care Group Leadership and Quality Group

Quarterly

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8. EQUALITY IMPACT ASSESSMENT SCREENING 8.1 Privacy, Dignity and Respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’.

As a consequence the Trust is required to articulate its intent to deliver care with privacy and dignity that treats all patients with respect.

Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

Indicate how this will be met

All staff, contractors and partner organisations working on behalf of the Trust must follow the requirements of this policy and other related policies, particularly those relating to Information Governance. All health professionals must also meet their own professional codes of conduct in relation to confidentiality.

8.2 Mental Capacity Act

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals capacity to participate in the decision making process.

Consequently, no intervention should be carried out without either the individual’s valid consent, or the powers included in a legal framework, or by order of the Court.

Therefore, the Trust is required to make sure that all staff working with individuals who use our service is familiar with the provisions within the Mental Capacity Act. For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act 2005 to ensure that the interests of an individual whose capacity is in question can continue to make as many decisions for themselves as possible.

Indicate How This Will Be Achieved.

All individuals involved in the implementation of this policy should do so in accordance with the Guiding Principles of the Mental Capacity Act 2005. (Section 1)

9. LINKS TO ANY ASSOCIATED DOCUMENTS

All of the documents listed below cover various aspects of record keeping, maintenance and storage and staff should make themselves familiar with them.

Access to Health Records Policy (General Policies, Policy 1) Agile Working Policy Care Programme Approach Policy

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Clinical Risk Assessment and Management Policy Data Protection Policy (General Policies, Policy 14) Freedom of Information Policy Informatics Security Policy Informatics and Knowledge Services Policies) Information Governance Policy (Informatics and Knowledge Services Policies) Information Sharing with External Organisations Policy Life Cycle of Clinical Records and Corporate Records. Managing Transgender, Adoption and Witness Protection Records SOP Mandatory and Statutory Training Policy Mental Capacity Act (2005) Doncaster Joint Agency Agreement and Guidance for Staff Mobile Devices, Guidance for their Safe and Secure Use (Informatics and Knowledge Services Policies) Offsite Storage SOP Policy for Consent to Examination or Treatment PPI Strategy RDaSH Retention & Disposal Policy for Records Management Scanning of Physical Documentation Policy SystmOne Process Maps SystmOne SOPs Use of Electronic Messaging to Communicate with Patients Policy Wellness Recovery Action Plans

10. REFERENCES

British Medical Association (BMA) Retention of Health Records https://www.bma.org.uk/advice/employment/ethics/confidentiality-and-health-records/retention-of-health-records Data Protection Act 1998 Department of Health (DH) The Records Management Code of Practice for Health and Social Care 2016 accessed at https://digital.nhs.uk/binaries/content/assets/legacy/pdf/n/b/records-management-cop-hsc-2016.pdf DoH Copying Letters to Patients Learning Resource (2006) Freedom of information Act 2000 General Medical Council (2001) Health Records Act applies to England, Scotland and Wales accessed at http://www.legislation.gov.uk/ukpga/1990/23 Mental Capacity Act (2005)

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NHS Choices: 'Accessing health records' http://www.nhs.uk/NHSEngland/thenhs/records/healthrecords/Pages/what_to_do.aspx NHS Digital (2016) Records management code of practice for health and social care: Sets out standards required for the management of records for organisations who work within, or under contract to the NHS in England https://digital.nhs.uk/information-governance-alliance NMC Record keeping guidance accessed at https://www.nmc.org.uk/standards/code/record-keeping/ Nursing and Midwifery Council (NMC) The NMC Code for Nurses and Midwives: Professional standards of practice and behaviour for nurses and midwives http://www.nmc.org.uk/standards/code/ Record Management http://systems.digital.nhs.uk/infogov/records

Royal College of Nursing (RCN) Delegating record keeping and countersigning records https://www.rcn.org.uk/-/media/royal-college-of-nursing/documents/publications/2017/june/pub-006134.pdf

Royal College of Psychiatrists (2004)

11. APPENDICES

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Appendix 1

COPYING LETTERS TO PATIENTS

Assess whether the patient is able to benefit from copy letters

[Consider Mental Capacity & Gillick Competence]

Yes No

Ask if patient would like to receive copy letters [provide information leaflet (appendix 2) and explain exclusions

Record in notes – review minimum 12 months

No Yes

Record in notes – review minimum – 12 months

Is the content of this letter likely to impair the therapeutic process?

Is there 3rd party information which needs to be withheld?

Is there a need for special safeguards for Confidentiality?

Yes No No Yes Yes No

Copy letter Copy letter

Write letter

Consider

No letter – discuss with team colleagues and record in notes

No letter – discuss with team colleagues and record in notes

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Appendix 2

ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST

PATIENT INFORMATION

COPYING LETTERS TO PATIENTS

Introduction

The NHS Plan, states, that patients/patients have the right to receive copies of any health professional’s letters written about them.

What is “copying patients letters” about?

As a general rule and where you agree, letters written by one health professional to another, about you, should be copied to you or where appropriate, your parent or legal guardian.

What constitutes a letter?

A letter includes communications between different health professionals, for instance those from and to your family doctor, hospital doctors, nurses, therapists, other health professionals and to social services / educational services [if you are a child or adolescent].

Information such as single test results will not be sent directly to you i.e. an x-ray and its report, results of blood tests etc.

When letters should not be copied

There may be reasons when the general policy of copying letters to patients will not be followed. This decision will be made by your Health Professional. These are:

- where you do not want a copy

- where the Health Professional feels that it may cause harm to you

- where the letter includes information about a third party who has not given consent

- where there are special safeguards for confidentiality

Consent to receipt of letters

It is for you to decide whether you wish to receive copies of letters written about you, by health professionals. You will be asked whether you want to receive a copy of any letter, written as a result of consultations with the Health Professional. There is a clear process for recording your views and these will be respected.

Capacity

There may be times when you feel you are unable to make decisions about whether you would like a copy of a letter.

Should this be the case we will already have a record of someone who will act on

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your behalf or represent your views. In these instances that person will be approached.

Carers

You may have carers, family members or others who are actively involved in your care. As carers, they need information and support from professionals involved in the treatment of the person they care for. With your consent, a copy of letters can be sent to your carer.

Occasionally, you may not want a letter copied or shown to your carer. In these circumstances, unless there is an over-riding reason to breach confidentiality, your wishes will be respected.

How is it to be done?

The person who writes the letter should be responsible for arranging that a copy is made and provided to you, after it is confirmed:

- that you wish to receive a copy

- how you want to receive it

- in what preferred format

Accurate Information

In order to fully comply with the “copying letters to patients” initiative it is important we ensure we hold accurate information about you.

It is very important that your contact details are correct therefore could you please inform us about any changes.

Further information When you receive copies of the letters you may want some of the content explaining or further information. If you wish to discuss this further you should contact: The Patient Advice and Liaison Service [PALS] on Tel: 0800 015 4334; they will be happy to assist with any queries that you have and try to address these. Withdrawal of Consent If you have given consent to receive copies of letters, you also have the right to change your mind and withdraw your consent.

If you wish to do this, please discuss this with your Health Professional at your next appointment.

Your right to withdraw consent will be respected.