Plain-English explanations of the technical terms and legislation used in this document.
- Asynchronous consultation
- A remote contact that does not happen in real time, for example where the patient completes an online questionnaire that a clinician reviews later.
- Caldicott Guardian
- The senior person responsible for protecting the confidentiality of people's health and care information.
- Caldicott principles
- A set of rules for handling confidential patient information, including sharing only the minimum needed, on a need-to-know basis, while still sharing when it is in the patient's interest.
- Care Quality Commission (CQC)
- The independent regulator of health and social care services in England.
- Common-law duty of confidentiality
- The long-standing legal duty to keep information given in confidence private and to use it only for the purpose for which it was shared.
- Contemporaneous record
- A clinical note written at the time of the contact, or as soon as possible afterwards, so it is accurate and complete.
- Continuity of care
- Coordinating a patient's care across providers so everyone involved has the information they need and nothing falls between services.
- Controlled drug
- A medicine whose supply, storage and records are tightly restricted by law because of its potential for misuse.
- Data Protection Act 2018
- The UK law that sits alongside the UK GDPR and governs how personal information must be handled.
- General Medical Council (GMC)
- The body that registers doctors in the UK and sets the standards they must meet.
- General practitioner (GP)
- A patient's registered family doctor or practice, which usually holds their main medical record.
- Good medical practice
- The General Medical Council's core guidance setting out the standards of conduct and care expected of every doctor.
- Information Commissioner's Office (ICO)
- The UK regulator that oversees data protection and can be told about serious personal data breaches.
- Informed consent
- Agreement to treatment or to information sharing given freely after the risks, benefits and alternatives have been clearly explained.
- Mental capacity
- Whether a person can understand and make a particular decision for themselves at the time it needs to be made.
- Modality
- The means by which a remote contact takes place, for example video, telephone, secure message or online questionnaire.
- Near miss
- An event that could have caused harm but did not, by chance or because it was caught in time.
- Personal data breach
- A security failure that leads to personal information being lost, stolen, altered or shared with the wrong person.
- Prescription-only medicine
- A medicine that may lawfully be supplied only on the instruction of an appropriate prescriber.
- Public interest
- A limited basis on which confidential information may be shared without consent, for example to prevent serious harm to the patient or others.
- Records Management Code of Practice
- National guidance on how long health and care records should be kept and how they should be managed and disposed of.
- Registered manager
- The person registered with the Care Quality Commission as responsible for the day-to-day running of a service.
- Regulated activity
- A type of care or treatment the law requires a provider to register with the regulator to deliver.
- Regulation 12 (Safe care and treatment)
- The part of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 requiring care and treatment to be provided safely.
- Regulation 17 (Good governance)
- The part of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 requiring good systems, record-keeping and oversight.
- Safeguarding
- Protecting people's health, wellbeing and rights and keeping them safe from abuse, harm or neglect.
- Safety-netting
- Clear advice to a patient on what to watch for, how quickly to act and where to get help if their condition changes or worsens.
- Single assessment framework
- The structure the Care Quality Commission uses to judge a service, built around quality statements and five key questions (safe, effective, caring, responsive, well-led).
- Special category data
- Sensitive personal information, including health data, that the law protects with extra safeguards.
- Standard Operating Procedure (SOP)
- A written, step-by-step procedure describing how a particular task is to be carried out consistently and safely.
- Subject access request (SAR)
- A person's legal right to ask for a copy of the personal information an organisation holds about them.
- Telehealth
- The delivery of health care at a distance using technology such as video, telephone or secure messaging.
- UK General Data Protection Regulation (UK GDPR)
- The UK's main data-protection law governing how personal information is collected and used.
- Vital interests
- A basis for sharing information without consent where it is necessary to protect someone's life.