Electronic Health Records, Confidentiality & Consent

• Your information

  Once we hear about you, your situation will be reviewed by a health professional.

  Community electronic health records will be looked to get information about you, but only from the relevant places and people. This is important because it means care can be directed to the right part of our service. It will then be allocated to a team member with the best skills to help.

  Our services will record all contact with you on a secure health record system called SystmOne. Records are completed carefully to ensure only personal information about you is recorded on your record.
  
  You have choices on how your information is shared, so when you meet with us or speak with us on the phone, we can explain these choices. 

  Our service follows national General Data Protection Regulations (GDPR) to ensure the information we see, hold and share is used properly and safely.
  
  Easy read guide - sharing information of your support needs

• Sharing out

  You can choose to share the contact you've had with Norfolk & Waveney Children and Young People’s Health Services through your electronic health record with other health services. This is known as consent to share out.

  You can choose not to share your record of contact with Norfolk & Waveney Children and Young People’s Health Services with other health services if you wish. This is called dissent to share out.

• Sharing in

  You can choose to share the contact with other services on your health record with Norfolk & Waveney Children and Young People’s Health Services, this is called consent to share in.

  You can choose not to share the health record of contact with other NHS services you access with Norfolk & Waveney Children and Young People’s Health Services. This is known as dissent to share in.

  You will be asked about these choices at all NHS services you access. 

  Sharing information can be useful. It lets all services see the assessment and care recorded by each other, and allows you to talk about it with them. However it is a personal decision.
  
  It's your choice and your treatment will not be affected by what you decide. Your decision will be recorded on your electronic record.

  Remember you can change your mind at any time. Just discuss it at your next appointment or call the service to let them know.

• Confidentiality & young people

  As you reach adolescence you start to become able to understand what services you need and what would be helpful to you. This is called having the ‘competence’ to make treatment decisions for yourself. 

  By law young people over 16 are considered to have capacity to decide for themselves. Once you have ‘capacity’ you can consent to your own treatment, and decide for yourself who is told about your care.

  All young people are different and many will have capacity before the age of 16. If you are under 16, there is guidance for professionals to follow to help them assess if you are able to safely decide what treatment you consent to. This is known as Gillick Competency.

  Before you consent to your own care, professionals need to be confident you can:

  • Understand information given to you in relation to a decision.
  • Remember the information long enough to make a decision.
  • Weigh up any pros and cons using the information available.
  • Communicate your decision in any way which can be recognised.

  The guidance is also used to decide if you can choose to keep your care private and confidential from your parents and carers.

  It is important to say that our team will always encourage you to share information about your care with your family. Practitioners will help you decide how you can comfortably share things with your parents and carers. We know that parents and carers can offer important support and understanding.

  If you refuse to share with your parents and carers, staff will ensure you know who to contact for help if you need it.

  Staff will share your confidential information without consent only if they feel you are at risk. If the level of concern is high they will follow safeguarding policies and procedures to keep you safe.
  
  Easy read guide - confidentiality