Legislation and guidelines in relation to patient records

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records

NICE- national institute for health and clinical excellence 

Records should be attained for 11 years or to the age of 25 children 

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NHS

Nhs records 

a standard chart (form FP25)

FP17 DC/ GP17DC- given to the patient ( treatment required/ NHS charges)

FP17- dental estimates form/ treatment required 

FP10- Prescriptions 

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HEALTH INFORMATION AND CONFIDENTIALITY

data protection act 1998

access to health records act 1990

freedom of information act 

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DATA PROTECTION ACT 1998

protect the confidentiality of sensitive personal data 

only make third party discolures under conditions of the act

Only be shared in order to provide that patient with appropate care and treatment and provisions of general health services 

NHS retain for 2 years

Medio-legally they should be held for 11 years or the age of 25 (child) 

Patients must not be discussed infront of other patients 

Privacy must be maintained when discussing personal matters with patients 

All written communications with patients should be sent in sealed envelopes 

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DISCLOSURE WITHOUT PATIENT CONCENT

- Under normal circumstances inof about a pt can only be disclosed to a third party with written consent 

IT CAN BE GIVEN UNDER THE CIRCUMSTANCES 

-assist a person/ persons involced in a raod traffc accident/ facial trauma prevent identification 

- Request by the dental practice board

- Provide info about a child to parent/ guardian 

- In the public interest 

- when disclosure is requested by court order 

- necessary to a solicitor or debt collector agency 

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ACCESS TO HEALTH RECORDS

- pt have the right under the access to health records act 1990 and data protection act 1998

- covers all medical and dental records written since 1991

- only their dentists can approve acess

- patient requests must be made in writing 

- dentists must respond within 40 days of fee payment 

- patient idenity must be checked before releasing records and must be realsed to the patient only

- once viewed/ inacuries can be ammened

- dental terminology/abbreviations or jargen must be explained on request 

DENTISTS CAN REFUSE DISCLOSE THE FOLLOWING 

- when it causes serious harm to pt

- When a second person is mentioned by name and has not given concent

- when access to their records after death has been refused by the patient before hand

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GDC / STANDARDS GUIDANCE AND CONFIDENTIALITY

Information governance 

NHS comliance

- data protection 

Information security 

information quality 

health records management 

corporate information 

It is required  'to ensure patient and data confidentiality and safe handling of sensitive information how information should be stored 

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