Records Access Form Records Access Form Records Access and Understanding Safety Checklist Questionnaire This form is used to sign people up for Full Records Access and Understanding Please complete all 10 questions. We will then process your request and send a reply back to confirm you have access to your electronic health records. It takes between 2-4 minutes to complete. Every person needs to complete this. If you are doing this on behalf of somebody else then please remember to state your relationship with the person and that you have permission to do so on their behalfName First Last Address Postcode Email Mobile Phone OptionalHome Phone Optional1. I am doing this questionnaire for myself? Yes No Please state your name, date of birth, postcode and relationship to the patient2. Can you read and understand English ? Yes No 3. Have you registered for ordering repeat prescriptions and booking appointments on-line? Yes No 4. Are you happy to use passwords to access your record? Yes No Please state why you are not happy to use a password5. After you have been to the doctor or to the hospital, you can check if the encounter has been recorded and what was discussed. Do you agree this is a good reason to have access to your records? Yes No Please state why you do NOT think this is a good idea Optional6. Would you like to feedback what you think of the Records Access system? Yes No 7. There maybe an instance when accessing your medical records online, you may read some information that could be shocking or upsetting. What do you do if this happens and you cannot speak to your doctor / nurse immediately? Please tick all options that apply Not view the test results but wait until you see the doctor / nurse Panic and get worked up Look at some of the recommended websites under self care on www.htmc.co.uk Wait and contact the practice the next working day Speak to a friend or family member whom you trust Contact 111 to get further information Contact GoToDoc, the Out of Hours service (details available at www.htmc.co.uk) Go to A&E for further help Other Please add any other options you may consider Optional8. You see a new letter has arrived in your electronic health record. You open up the letter to find it is about another patient in the practice. What do you do? Read it then tell others what the person suffers with Inform the practice Stay quiet and not tell anybody about it Other Please add any there options Optional9. Would it upset you if you read something somebody else has said about you with regards to your health? This does NOT mean others can see your record without your permission. No Yes – I don’t want this information kept in my record Yes – You should not believe what others say Yes – This could destroy our relationship I do not understand what this question means Don’t know Other Please state what other reason you may have Optional10. Do you feel you understand what Records Access means? Yes No Other Can you explain please? OptionalName OptionalThis field is for validation purposes and should be left unchanged.