Information Health Record

NHS Direct Wales Individual Health Record Information Line Script

What is the Individual Health Record?

The Individual Health Record is a summary of your GP record. It will let GPs and nurses in your local Out of Hours Service see some basic information about your medical history.

They will only be able to look at this information if you need care from the Out of Hours Service and you tell them that they can see it.

The information they can see includes your name, address and contact details, details of your current GP practice, what medication you’re taking or have been taking, medical problems you’ve seen your GP about, anything, like antibiotics, you are allergic to, and the results of any recent tests you may have had, for example, blood tests and x-rays.

Only the last two years of your medication history will be shown and only the previous year’s test results will be available.

Why do we need an IHR?

Access to information about you, when your own doctor is not available, will make it easier and safer for Out of Hours staff to look after you.

Who can look at my Individual Health Record?

Only Out of Hours GPs and nurses can see your Individual Health Record. They will only be able to see it when they are providing you with care in the Out of Hours Service and only when you tell them they can.
Do they need my permission to look at my Individual Health Record?

Yes. Each time you contact the Out of Hours Service, the medical staff involved in your care will ask, if they need to access your Individual Health Record, for your permission to do so. You can let them or tell them not to. Your decision will be respected and recorded on the system.

What if I can’t give my permission?

The Out of Hours medical staff will always act in your best interests when deciding whether they need to access your Individual Health Record if you cannot give your permission, for example if you are unconscious. Any decision to access your Individual Health Record when you are not able to give your permission will be recorded on the system with an explanation of why the decision was taken.

Will my GP record remain confidential?

Yes. Out-of-Hours staff have limited access to the medical information held about you by the GP practice. Strict controls ensure that your personal information is protected and remains confidential and all access will be recorded and checked. All NHS staff work to a ‘Code of Conduct’ and are bound by a duty of confidence.

What if I do not want to share sensitive information?

All information about your health is confidential, all health information is sensitive
Some very sensitive information will not be transferred from your GP system.

Information which may be considered more sensitive than normal (such as information on sexually transmissible diseases, HIV/AIDS, human fertilisation services and surgical or medical terminations of pregnancy) will be restricted in order to protect patient confidentiality.

Does the Individual Health Record form part of the national electronic care record being introduced in England?

No, the NHS Wales Individual Health Record for emergency care does not form part of the national electronic record being introduced by the NHS in England known as the Summary Care Record.

What if I want to Opt-Out?

Please arrange to speak to staff at your GP Practice to discuss your concerns or contact your health board. List of HB contacts.

Can I think about it and opt back in?

Yes. You can change your mind and opt back in.

Any additional questions:

Please refer to the appropriate Health Board in the first instance.

The Individual Health Record Patient - Frequently Asked Questions

What is the Individual Health Record?

The Individual Health Record is a copy of relevant information from your GP record which will let medical staff (GPs and nurses) in your local Out of Hours Service, see some basic information about your medical history.

Eventually, the Individual Health Record will be available to medical staff in other emergency and urgent health care settings.

Why is the Individual Health Record needed?

The aim is to provide better information about you to the medical staff providing out of hours and emergency care. This is expected to help improve the quality, safety and convenience of your care.

What sort of information is in my Individual Health Record?

It will have:

  •  Your name, address and contact details
  • Details of your current GP practice
  • What medication you’re taking or have been taking
  • Medical problems you’ve seen your GP about
  • Recorded allergies
  • Results of any recent tests you may have had, for example, blood tests and x-rays

Only the last two years of medication history and one year of test results will be shown.

It will not include details on:

  • Sexually transmitted diseases
  • HIV / AIDS
  • Human fertility and embryology
  • Terminations
  • Gender reassignment
  • Any private discussions you have had with your GP

Information of this type, according to a defined list, will not leave the GP Practice.

However, medications you are taking for any of these conditions will be included in your Individual Health Record. This is for safety reasons, to help stop the Out of Hours medical staff prescribing medication that may react badly with other medication you are already taking.

Who can look at my Individual Health Record?

Initially, only Out of Hours medical staff (GPs and nurses) will be able to see your Individual Health Record. They will only be able to see it when they are providing you with care in the Out of Hours Service and only when you tell them they can.

However, use of the Individual Health Record has been extended within Gwent, to include clinicians within the Medical Assessment Unit in the Royal Gwent Hospital, Newport.

Can I access my Individual Health Record?

You can apply for a copy of your Out of Hours records under the Data protection Act 1998, by writing to the Out of Hours Service provider:

Aneurin Bevan Health Board - Medico-Legal Department, Aneurin Bevan Health Board, Royal Gwent Hospital, Newport, NP20 2UB.

Abertawe Bro Morgannwg University Health Board - Operational Lead,
ABMU HB Out-of-Hours Service, c/o The Grove Medical Centre, 6 Uplands Terrace, Uplands, SWANSEA, SA2 0GU

Betsi Cadwaladr Health Board - Out of Hours Service, Eryldon, Campbell Road, Caernarfon, Gwynedd, LL55 1HU

Cwm Taf Health Board - GP Out-of-Hours Manager, Cwm Taf Health Board, Ty Elai Contact Centre, Dinas Isaf East, Williamstown, Tonypandy, CF40 1NY

Cardiff and Vale Health Board - Hywel Dda Health Board - Information Governance Manager, Hywel Dda Health Board, West Wales General Hospital, Dolgwili Road, Carmarthen, Carmarthenshire, SA31 2AF

If you want a copy of your full GP record you will have to write to your GP practice.

Do they need my permission to look at my Individual Health Record?

Yes. Each time you contact the Out of Hours Service, the medical staff involved in your care will ask for permission to view your IHR, if it is necessary for them to do so. You can let them or tell them not to. Your decision will be respected and recorded on the system.

What if I can’t give my permission?

There may be occasions when Out of Hours medical staff may look at your IHR without your agreement, for example in an emergency when you cannot give your consent. The Out of Hours medical staff will always act in your best interests when deciding whether they need to access your Individual Health Record. Any decision to access your Individual Health Record when you are not able to give your permission will be recorded on the system with an explanation of why the decision was taken.

What if I don’t want an Individual Health Record?

You have the right to opt out at any stage. You can do this by contacting your GP Practice who will help you through the opt out process. This will stop any release of your information from your GP Practice to the Individual Health Record.

If you change to another practice you will need to contact your new GP to re opt out.
Can I change my mind and opt back in?

Yes, you can change your mind and opt back in. You can do this by writing to your GP practice.
How do I know my information will be safe?

NHS Wales protects the information using the highest standards of security. Access is controlled, with medical staff needing their own username and password to be able to look at records. The NHS keeps track of every time someone looks at a record. It then checks to make sure that person was allowed to look at the record.

For security the Individual Health Record can’t be printed or saved onto laptops or CDs.

Why haven’t I heard about this in Wales?

The system has been available only in Gwent since its launch in November 2006, but the service was been extended to Hywel Dda as of December 2009.

The NHS Wales Informatics Service is working together with Health Boards to roll out the solution further. The Individual Health Record will be put into place in phases by each health care community across Wales.

Whose idea was this?

In 2005, NHS Wales medical staff and managers got together to find new ways of improving standards of care. One idea was the Out of Hours Individual Health Record. Patient panels, local GPs and several medical organisations then gave their opinion. The overwhelming view was that an emergency care Individual Health Record would work well in Wales.

Will the Individual Health Record form part of the national electronic care record being introduced in England?

No, the NHS Wales Individual Health Record for emergency care does not form part of the national electronic record being introduced by the NHS in England known as the Summary Care Record.

If I use an Out of Hours service outside of my practice area will they be able to access my IHR?

No, your IHR is only available across your local health board.

Patient links:

www.wales.nhs.uk/individualhealthrecord
www.wales.nhs.uk/cofnodiechydunigol

NHS links:

www.wales.nhs.uk/nwis/ihr
www.wales.nhs.uk/nwis/ciu

Downloads:

Patient Information Leaflet
Health Record A4 poster (English)
Health Record A4 poster (Welsh)

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