Sensitive notes, safeguarding and online access

Some notes can increase risk if seen by the wrong person. This matters where there is domestic abuse, coercion, safeguarding concern, proxy access, third-party information, mental health crisis, sexual health issues or unsafe contact details.

Record, but place carefully

Sensitive information should not be omitted because it is difficult to record. The practice may need those facts to protect the patient. Record them in the appropriate field, set visibility correctly and follow escalation procedures.

Reception staff should not decide record visibility alone. If a note might be visible online, identify a third party, or increase risk if viewed by a patient, proxy or abuser, follow the local safeguarding or records process and seek advice.

Risk areas to notice

• Proxy access: another person may see appointment notes, messages or record entries.
• Safe contact: texts, voicemails or letters may be monitored.
• Third-party information: relatives or agencies may share concerns that need careful handling.
• Safeguarding: facts may be essential but must be recorded safely.
• Online forms: patient wording may flow into visible records or tasks.

Ask before you enter unsafe detail

Where there is time and uncertainty, pause and ask the safeguarding lead, duty clinician, practice manager, records lead or information governance lead. If immediate safety is at risk, escalate urgently through the practice process.

Sensitive information should be recorded safely, not omitted, hidden informally or placed where it may increase risk.

Safeguarding record visibility