Your HIV Information

This leaflet aims to help you understand how and why information about your HIV status, HIV medication and HIV care is recorded in your hospital records by other hospital teams and why this information may be communicated or visible to other services such as your GP or other hospital teams.

What you need to know

Health care records nationally and at Leeds Teaching Hospitals Trust (LTHT) are increasingly moving to electronic records. If you get any health care at LTHT it is likely that this will be recorded electronically. Most GPs also have access to this electronic record.

Most of our Brotherton Wing Clinic (BWC) service users are happy for their HIV clinic information to be recorded on their hospital records and shared with their GP. This enables safer clinical care and is what we would recommend. Unlike most other clinical services, BWC is able to use a different clinical record system to the rest of the hospital if needed.

We (BWC) are, therefore, are able to offer you the option of keeping your HIV outpatient records separate from the rest of your hospital record because we have access to a separate electronic record system. This allows us to record medical information relating to your HIV status, HIV medications and HIV care without it being visible to other colleagues working at LTHT or your GP. We do not write to your GP without your permission.

Other teams within LTHT do not have this option and will therefore record your medical information and the health care you receive on your LTHT hospital record. Similarly, other hospitals would record your medical information and care on their own hospital records. Other medical teams usually also automatically write to your GP.

The recording of your medical information and care remains confidential (see below), and should only be accessed by those directly involved in your care at the hospital or at your GP practice. Below are some common examples of how other clinical services record HIV treatment and care information on your hospital record.

This information is recorded because it is medically relevant and important for your care.

Whilst we respect and uphold your decision to decline consent for the HIV clinic (BWC) team to record your HIV out-patient treatment and care information on your LTHT hospital record and / or communicate with your GP, we also support our LTHT and other hospital colleagues in recording this important information in your hospital record. This is because all healthcare professionals have a duty to maintain accurate client records (see next page) and this is crucial to your health and well-being.

Confidentiality

All information recorded in your hospital record, including information about your HIV and related care, is confidential. Data Protection laws and NHS local and national policies direct all healthcare professions to uphold certain standards of confidentiality including the recording of your personal medical information. Healthcare workers should only access your patient record if they have a legitimate reason to do so e.g. to ensure health care needs are met. The access of your patient records by healthcare professions can be investigated if you have any concerns.

Writing accurate medical records – Our Duty of Care

The General Medical Council and The Nursing and Midwifery Council (NMC) directs Doctors and Nurses to keep accurate medical records and that their documentation is –

• Formally recorded, clear, accurate, legible, signed and dated.
• Should cover all relevant clinical findings, clinical decisions made and actions required.
• Should include all medications prescribed and investigations requested.

In addition, NHS digital suggests that ‘all care records should be … complete, accurate and fit for purpose. Information is not safe if it is not accurate. It is the responsibility of each member of the team to ensure this’.

Doctors, nurses, and other healthcare professionals have a duty to work professionally, ethically, effectively, safely and, with your best interests at heart. Record-keeping and the documentation of clinically relevant information is important and must provide an honest and accurate account of the care provided. High standards in record keeping helps to avoid causing harm to you. For example, if information about your HIV treatment is not clearly and accurately documented in your hospital record, then you might be prescribed medication that interferes with your HIV medication.

Further reading

HIV Patient Information and NHS Confidentiality – National AIDS Trust

www.nat.org.uk/sites/default/files/publications
/Jan-2014-HIV-Patient-Confidentiality-NHS.pdf

Further information / questions

If you need further information or have any other questions about how your HIV information is stored and shared at LTHT please speak to one of the BWC team or contact us on:
0113 392 6762.

https://www.leedsth.nhs.uk/services/hiv-outpatient-service/

Brotherton Wing Clinic

Understanding how your HIV information is recorded and shared by clinical services other than Brotherton Wing Clinic

Dear Service user,

As you have declined consent for your Brotherton Wing Clinic HIV treatment and care information to be stored on your Leeds Teaching Hospitals Trust (LTHT) electronic patient record and / or you have declined consent for the Brotherton Wing Clinic team to communicate with your GP about your HIV treatment and care we need to ensure that you understand that other clinical services / departments / hospitals are not able to withhold this information from your electronic patient record and that the information they record about your HIV treatment and care will be visible on your LTHT electronic patient record and may be visible to or shared with your GP / other hospitals.

To confirm that you have read and understand the above patient information in relation to how your HIV information is recorded and shared by clinical services other than Brotherton Wing Clinic, please print and complete the last page of the PDF linked at the top of this page.