Cornerstone SurgeryCornerstone Surgery Drs Consiglio & SuttonDrs Consiglio & Sutton
Fingerpost Park Health Centre, Atlas St, St. Helens, WA9 1LN
Tel: 01744 738835 / 01744 647040  |  Fax: 01744 454624
Fingerpost Park Health Centre,
Atlas St, St. Helens, WA9 1LN
Tel: 01744 738835 / 01744 647040
Fax: 01744 454624

Detailed Coded Record Access

If you requested access to medical records when registering for Online Patient Services, you will be able to view medication, allergies and immunisation history. Detailed Coded Record Access allows you to also view problems, test results, consultations and documents sent by the Practice, as well as documents received by the Practice

Online access to medical records is different to a request to view or for a copy of your full medical record under the terms of the Data Protection Act, which is known as a Subject Access Request

To make a Subject Access Request, please apply in writing to the Practice Manager – Do not use the Detailed Coded Record Access request form

Access is granted at the discretion of the GPs

In accordance with the Data Protection law, the GPs have a duty to restrict access to medical information where:

  • it is considered that access would disclose information likely to cause harm to the physical or mental health of the patient or of any other individuals
  • access would lead to the disclosure of the identity of a 3rd party who has not consented to the disclosure of the information, unless that individual is a health professional who has been involved in the care of the patient
All requests for Detailed Coded Record Access must be approved by a GP, and your full medical record will be reviewed before access is granted. The Practice will aim to review your record and provide access within 30 days of receiving your completed form. If, however, we cannot provide access within 30 days, we will notify you

Should the GP feel that there is information in your record which is not appropriate to be accessed, we will take the following actions:

  • hide individual entries from the online medical record view
  • restrict access to specific sections, e.g. only enabling access to entries in Consultations after a particular date
  • withhold access to specific sections, e.g. not enabling access to Documents

Entries relating to the following areas are classed as being 'sensitive', and the Practice will, by default, hide them from the online medical record view:

  • gender reassignment
  • assisted conception and in vitro fertilisation (IVF)
  • sexually transmitted diseases (STDs)
  • termination of pregnancy
  • miscarriage
  • convictions & imprisonment
  • abuse
  • adoption
There is, however, an option on the application form to request that information for individual areas be assessed for inclusion in your medical record view - This information is still subject to GP approval

If the GP feels that potentially harmful or 3rd party information cannot be effectively restricted, or that access is not in your best interest, the Practice has the right to refuse your request for Detailed Coded Record Access

Record accuracy

The Practice makes every effort to record information as accurately as possible, however, should you find information that you do not feel is correct, whether inaccuracies, errors or omissions, please notify the Practice in writing:

  • be as specific as possible ensuring that you include the date of the entries, and why you consider them to be incorrect
  • send the information to the Practice for the attention of the Practice Manager

The Practice will correct information where appropriate, but will neither amend nor remove factually correct information

Viewing your Medical Record

Important things to consider:

You may view information that you find upsetting

  • There may be something in your medical record that you have forgotten about
  • If you have been given access to test results or letters, you may see information that alarms you. This may occur before the GP has been able to discuss the results with you or while the surgery is closed and you will not be able to contact them

Medical records may contain information that you do not understand, or which can be mis-interpreted

  • Medical records are primarily 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
  • How a GP reads and understands information will be different to the way a person without clinical training reads and understands information
  • Information in GP clinical systems is recorded using a database of pre-defined 'Clinical Terms' which are standarised across all GP systems. Clinicians have the facility to add additional free-text to these pre-defined terms
  • Words used in clinical records may not mean what you think they mean:
    • Chronic - this means 'persistent, long-term or long-standing' - it does not mean 'severe'
      e.g. chronic back pain doesn't mean it is extremely painful, it means that you have had, or are likely to have it, for a long time

Blood test results in EMIS are classified in two ways:

  1. normal - i.e. within the normal range
  2. abnormal - i.e. outside the normal range

  3. The normal ranges for test results are based on agreed national or local trends. The classification of 'Normal' or 'Abnormal' is placed on the result by the laboratory conducting the test
  • A test result may be within the normal range, but could be at the lower or upper ends of the range, and may still require treatment
  • A test result may be just outside the normal range and appear as 'Abnormal', however the GP may consider that it is clinically appropriate to re-classify it as 'normal' or 'essentially normal', and decide that no action is currently required
  • A test result outside the normal range would be expected for patients with particular conditions – the result may be considered ‘normal’ given the patient’s medical history
    e.g. a patient with diabetes will have a HbA1c blood test result which is outside the normal range

When processing blood test results the GP will take the individual patient's medical history & treatment into consideration, and may add an additional free-text comment to the result which reflects the patient's circumstances

Should the GP decide that further action is required, they will arrange for the Practice to contact you:

  • you may be invited to make a telephone triage appointment
  • we may write to you, asking you to attend for another blood test on a date within the next 6 weeks
  • if the GP decides that a repeat test is required, but does not need to happen within the next 6 weeks, a diary date will be added to your record for when the test is due. The Practice will then write to you when the test is due

Requesting Detailed Coded Record Access

In order to request Detailed Coded Record Access, you will need to complete and return an application form; this is different to the application form used when registering for Online Patient Services. There are 2 types of application available:

For more information on when you should make a patient or proxy application please visit our Activating Online Patient Services page

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Last update 25/06/18