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wales.nhs.uk : Individual Health Record View

Organization : NHS Wales
Type of Facility : Individual Health Record View
Country: Wales

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Website : http://www.wales.nhs.uk/nwis/page/52642
IHR Here : http://www.wales.nhs.uk/

View Health Records:

NHS Wales in partnership with the Informatics Service is bringing in a number of ways to view records electronically while still ensuring information is safe and secure. You can also find out more how patient details are handled.

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Individual Health Record:
The most complete record of a patient’s care is kept by their GP.

Sometimes, doctors in an out-of-hours clinic, or emergency care settings need quick access to vital information, but it’s not available because the GP’s surgery is closed for the evening or weekend.

Working closely with health professionals, we have developed the Individual Health Record (IHR).

Secure access :
The Individual Health Record is ‘view only.’ It can only be accessed under certain conditions by authorised staff using a computer within an Out of Hours (OOH) clinic or Medical Assessment Unit (MAU).

A health professional must have patient consent before accessing the Individual Health Record, unless the patient is unable to do so.

Access to the Individual Health Record is:
** monitored to safeguard patient confidentiality and
** there are numerous checks to make sure only the right people are accessing the right information

NHS Wales keeps a detailed audit log that records:
** who looked at a record
** when they did, and
** whether they had permission from the patient

The access log is kept for administrative and security reasons only and it contains no information about a patients’ health.

Why have an Individual Health Record?:
Without an Individual Health Record, medical staff providing out of hours or urgent care only have the medical history and medication details that you give them during your visit.

If this information is incomplete, it may reduce the safety and quality of the service that can be provided to you in an urgent medical situation, although the out of hours and emergency services will always strive to give you the best possible care.

The Out of Hours services provide urgent GP care on behalf of your GP for 118 hours per week, over two thirds of the total time.

You will help doctors and nurses working in out of hours to deliver faster and, possibly, better care to you if they have access to your Individual Health Record (IHR).

The benefits of having an IHR include:
Improved:
** quality and convenience of care for patients
** patient safety
** communications with (and between) medical staff

Increased:
** ability to diagnose in urgent situations
** speed of treatment
** appropriateness of treatment location
** convenience of care

To enhance the safety and quality of care provided in all emergency settings including accident and emergency, during acute admissions to hospital or other community based services

What does the IHR contain?:
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.

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