LONDON’S GLOBAL UNIVERSITY
SLMS Disclosures of PID by telephone
– Standard Operating Procedure
1. Document Information
Document Name
Author
Issue Date
Approved By
Next review
SLMS-IG04c Disclosures of PID by telephone – Standard
Operating Procedure
Shane Murphy
13/09/2013
Chair of SLMS IGSG
Three years
2. Document History
Version
0.1
0.2
1.0
Date
13/09/2013
24/09/2013
04/11/2013
Summary of change
First draft for discussion
Updated, incorporating comments from Trevor Peacock
Approved by the Chair of IGSG
SLMS-IG04c Disclosures of PID by Telephone –
Standard Operating Procedure v1.0
Page 1 of 3
Disclosures of PID by telephone – Standard Operating Procedure
1.0
Introduction
1.1
Verbal transmission of Patient Identifiable Data (PID) needs to be carefully managed because
they are subject to the requirements of the Data Protection Act 1998 and common law duty of
confidentiality. The use of verbal transmission for PID should be agreed with the recipient
beforehand as part of informed consent.
2.0
Key objectives
2.1
To minimise the risk of disclosure during verbal transmission of medical PID, the key objectives
below are followed:
•
•
•
•
PID provided by authorised and trained staff
Identification of the patient
Identification of the individual (authorised recipient) receiving the PID, beyond reasonable
doubt
Confirmation that the circumstances for confidentiality and privacy are not compromised
for either party
3.0
Authorised Staff
3.1
Only suitably trained and authorised staff should provide PID over the phone.
3.2
A list of the type of PID that may be conveyed by telephone, through authorised staff, must be
readily available to staff.
4.0
Patient Identification
4.1
Essential that the patient is identified in accordance with local procedures, including the use of
pseudonymisation coding.
5.0
PID Reception
5.1
Local system for identity checks must be in place. In addition to the personal identity checks of
confirming patient full name, date of birth and address, a secure passphrase should be used. The
personal identity checks mentioned will also be known to other members of the family. The
secure passphrase will assist in maintaining confidentiality.
5.2
The use of known telephone numbers is a requirement. Under no circumstances should PID be
given to an individual calling from an unknown telephone number.
5.3
PID must not be given to any unauthorised persons with the exception of protecting the vital
interests of the data subject. Such a disclosure should be authorized by the PI or their delegated
representative)
SLMS-IG04c Disclosures of PID by Telephone –
Standard Operating Procedure v1.0
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5.4
The recipient must confirm that they are in a location that will not be compromised in relation to
privacy and confidentiality.
6.0
Quality Checks
6.1
The person receiving the PID must comprehend the information provided.
6.2
A verification process must be followed. The disclosing party should request the individual to
repeat the information imparted to ensure they have understood.
6.3
Care should be taken to understand the capacity of the person receiving the PID to comprehend
the details. In such circumstances where the individual is not capable of understanding the
details, alternative methods should be investigated and utilised. The alternative method may for
example include providing the details to the patient’s GP.
6.4
A file record of the telephone conversation should be made that includes as a minimum:
•
•
•
•
•
•
•
Name of patient
Name of authorised recipient
Name of member of staff
Method of communication (i.e. telephone call should be transcribed to avoid any
confusion with any paper based PID that are conveyed)
Details of the PID provided
Date and time of the call
Comments and confirmation received from the authorised recipient
7.0
PID Requests
7.1
The patient and the requesting recipient must be accurately identified using the agreed local
protocols that include but are not limited to the following:
•
•
•
•
•
Full name
DOB
Address including full postcode
Known phone number
Security passphrase
7.2
Confirm the correct spelling of the patient’s name including the above bullet points on the
computer or other information system.
7.3
If the caller is unable to completely satisfy the agreed local protocol the PID must not be
provided.
7.4
Request the authorised caller to repeat the PID to verify that the information has been conveyed
accurately.
7.5
A full file record of the telephone conversation must be transcribed, as specified in 6.4 above.
SLMS-IG04c Disclosures of PID by Telephone –
Standard Operating Procedure v1.0
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