Information governance

1. 41. Doctors need accurate, up-to-date and accessible information to deliver good and safe care to patients. Patients need to understand how information about them will be collected, stored and used and how their confidentiality and privacy will be protected. Good information governance systems can help to achieve this and contribute to providing high quality and safe care. They can also provide valuable information to allow teams and services to improve the quality and safety of care they deliver. All doctors have a role to play in contributing to these systems.

All doctors

1. 42. You must keep accurate and clear patient records following the advice in Good Medical Practice.² You should make sure that non-clinical records you keep, including financial records, are clear, accurate and up to date.
2. 43. You must follow the guidance in Confidentiality on protecting information and disclosing information for patient care or secondary purposes.⁶
3. 44. You should be familiar with, and follow, the confidentiality, data protection and record management policies and procedures where you work and know where to get advice on these issues

Doctors with extra responsibilities

1. 45. If you are responsible for managing patient records or other patient information, you must follow the specific guidance for managers on protecting information set out in Confidentiality.⁷
2. 46. You must make sure that any other records you are responsible for, including financial, management or human resources records, or records relating to complaints, are kept securely and are clear, accurate and up to date.
3. 47. You must make sure that records you are responsible for are made, stored, transferred and disposed of in line with the Data Protection Act 1998 and other relevant legislation.