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x-ray medical record

The Process for accessing your NHS Mecical Records

Granting patients the statutory right to have access to their medical records is relatively recent, having its foundation in the Access to Health Records Act 1990 which came into force on 1st November 1991. As a result of this Act, subject to certain safeguards, patients were allowed to see their own manual health records made after this date and earlier records if they were necessary to understand the later ones.

There was no general statutory right to see manual records made before November 1991, although the NHS Executive made it clear that 'access should be given whenever possible'. Access to medical records of someone who has died is still governed under this Act. As of 1st March 2000 the Data Protection Act 1998 came into force (replacing the Data Protection Act of 1984). This Act now permits access to all manual health records whenever made, subject to specified exceptions. The Act also covers electronic records as well as manual records. This Act governs all living patients.

Other laws which have a bearing upon patients' rights to access information about themselves are the following
  • The Access to Personal Files Act 1987 which concerns personal information held by local authority social services - this may be relevant in cases of joint care
  • The Access to Medical Reports Act 1988 in respect of reports for employers and insurance companies Do I have a right to see my medical records? Yes, you have a right to see your medical records under the Data Protection Act 1998.
There are certain exceptions to this right. These are the most important:
  • Access may be refused if healthcare professionals believe that information in the records would be likely to cause serious harm to the patient or to another person
  • Details about third parties might be removed from the records
  • If you are applying for access on behalf of someone else, you will not be given information which the patient gave to his or her doctor on the understanding that it would remain confidential

Do I have a right to directly inspect my records?

No, although it is permitted if the 'data controller', usually your General Practitioner (GP) or the health authority, agrees.

What's in them?

Your medical records consist of a file of notes, letters, charts, x-rays, the results of tests, correspondence etc. regarding any treatment you have received from the NHS during your lifetime.

Why should you want to see them?

There are many reasons why you may want to obtain access to your medical records.
  • You may wish to make a complaint about how your healthcare was managed.
  • You may wish to make a complaint about how someone else's healthcare has been managed, for example a child for whom you have parental responsibility, or perhaps a relative.
  • You may wish to add new information to your health records if you consider that there have been mistakes or inaccuracies.
  • You may have moved abroad and need to pass your records to your new doctor.
  • You may be applying for residency in the United States and need your records for the application procedure.
  • You may simply wish to find out background information in relation to your healthcare.
The information contained within your medical records might help you to find out more about what happened and confirm factual details.

Do I have to give a reason for seeking access?

No, unless you are seeking access to medical records with a view to commencing legal proceedings (pursuant to the Clinical Negligence Pre-action Protocol).

Where are they held?

Your GP holds your medical records. Notes from treatment received elsewhere, such as in a hospital, will be kept there. But your GP should also receive a summary report, and this will be added to your medical records. You can access records kept by other healthcare professionals such as dentists and opticians by following the same procedure as for your GP or hospital.

Your medical records will be held by your GP. Notes generated by treatment undergone elsewhere, for example in a hospital or clinic will be kept on-site, but your GP should receive a summary report from other treatment received by you to add to your medical records.

Who holds my records if I do not have a GP?

Your records will be held by the local health authority or health board (in Scotland) on whose medical list your most recent GP was included.

How long are they held?

Hospital records

Hospital records are normally held for a minimum of 8 years after the conclusion of treatment but but there are lots of exceptions e.g. Children and young people, maternity records, mental health records etc.

GP Records

GP records are normally held for 10 years after the conclusion of treatment, the patient's death or after the patient has permanently left the country. Again there are lots of exceptions.

Who has access to them?

As of the 24th October 2001, the Data Protection Act 1988 'Subject Access' superceded the Access to Health Records Act 1990, except in the case of a deceased person when the Access to Health Records Act 1990 will still apply. Everyone has the right to access personal data held about themselves in either computerized or manual form, whenever the record was made. This includes NHS medical records and private records made by doctors and other health professionals.
  • You.
  • Another person with your written permission.
  • A parent or guardian of a person under 16, if that person agrees.
  • A court appointed representative of someone who is not able to manage their own affairs.
Where the patient has died, the personal representatives and anyone with a claim arising out of death, may apply to see the records, or part of them. The person holding the records need not disclose anything that dates from before November 1991.

Why may access by denied?

There are some exceptions:
  • Access may be refused if healthcare professionals believe that information in the records is likely to cause serious harm to the patient or another person
  • Details about third parties might be removed from the records
If you are applying for access on behalf of someone else, you will need their consent or a power of attorney
  • when the Health Professional thinks access is likely to cause you or anyone else serious physical and mental harm.
  • when a record contains details that the patient has asked not to be revealed to a third party.
  • when disclosing the records would reveal information that relates to or identifies another person unless their consent has been given; except where it is reasonable to disclose the records without that person's consent.
where it is not possible to supply you with a copy of the required information (because for instance the records have been destroyed under the Guidelines laid down in the HSC 1999/053).

What other healthcare records are there?

You may access health records kept by health professionals other than GPs and hospital doctors, for example, dentists and opticians using the same procedures as for your GP or hospital.

What is the procedure to access them

You can make an informal request to see your medical records. You could do this during a consultation, or by ringing the surgery or hospital and arranging a time to visit and see your records. You can make a formal request to see your records and this must be in writing (see Sample letter). Your doctor or hospital may give you a form to fill in instead of writing a letter. Remember to keep a copy of all your correspondence. Each practice or hospital is different and will influence whether you start by applying informally or whether you make a formal request first.

Request access informally

Your first step should probably be just to ask your GP or health authority if you can directly inspect them, although this isn't a right. You could also ring the surgery or hospital and arrange a time to visit.

Request access formally

You can also apply for access to your medical records formally in writing. If records are held at your doctor's surgery, you should write to your doctor direct or to the practice manager. The Information Commission recommends that you send the letter by recorded delivery. If the records are held at a hospital, you should address the letter to your hospital Patients Services Manager or Medical Records officer. It is worth asking if there is a form you can fill in.

The advantage of applying in writing is that you are entitled by law to receive a response no later than 40 days after your application was received.

Proof of identity: You may be asked for proof of identity if you are applying to see medical records at places other than your GP surgery. You will need to ask for the relevant form and get a witness to sign to confirm your identity.

Here is a suggeted letter you can employ.

Dear

I would like to make an application to see my medical records under the Data Protection Act 1998 (living patients)/under the Access to Health Records Act 1990 (deceased patients)*. I wish to inspect the records made during the period (approximate date) to (approximate date). I should be grateful if you would send me the appropriate application form and let me know what the fee would be if this is necessary.

Yours sincerely,

Name

Tips

  • Be tenacious but always polite
  • It is worth talking to the practice manager of the surgery. Different surgeries have different systems in place
  • Be prepared to chase up the surgery if you feel the process is taking longer than expected
  • Always keep a record of all of your communications on file
  • Contact the Patients Association if you want expert advice in accessing the NHS complaints procedure

To whom should I write?

If the records you wish to see are held at your doctor's surgery, you should write to your doctor direct or to the practice manager. If the records you wish to see are held at a hospital, you should address the letter to the Health Records Manager at the hospital address. If the records you wish to see are held at the health authority, you should address the letter to the Patient Services Manager or Medical Records Officer.

What are the advantages of applying formally?

If you apply informally, you are not legally bound to receive a response. If, however, you apply in writing, you are entitled by law to receive a response no later than 40 days after your application was received. In exceptional circumstances, where this is not possible within this period, you should be advised accordingly.

Do I have to prove who I am and how do I do this?

Yes you do. Further to your first letter asking to see your medical records you will be sent an application form, or a request, asking for personal identification, usually a signature verifying your identity from another person who knows you. If you are applying to your GP or hospital this may not be necessary. If you are applying to a health authority, you will certainly have to provide this. Apply in writing to the person who holds your record to request access to see them. Ask your Health Professional at time of consultation or while an inpatient to show and if necessary explain your current episode of care to you. You will need the patients written consent if you wish to inspect their record. If you wish to see the records of a patient who has died you must be either the legal personal representative or someone who has a legal claim arising out of the death. If you want a copy of the records or a written explanation of any information in them you must make a written request to the person who holds your records. You will be asked to complete a form for this purpose. You may also have to produce some proof of your identity. It may be possible to be shown the records immediately upon request. (Only if the consultant concerned is available to sit with the patient and only then those notes for the consultant's speciality.) if not, on application an appointment will be made for you to see them. If you have made a written request for copies, these will be sent to you on payment of the appropriate fee. You may not want copies of all your records. The record holder will ask you to say which parts you want so as to save time and expense.

How long should I expect to wait for an appointment to go into view my medical records?

This is not specified but if you feel that your request is not being dealt with promptly and that you are being subjected to an unreasonable wait, ring your surgery/hospital/health authority and ask for a reason for the delay. If your needs are still not met you may consider making a complaint (see How do I make a complaint?).

How does the surgery/hospital/health authority know which parts of my medical records I need?

If you are visiting in person to see your medical records, this does not apply. If you require copies of your records or parts thereof, you can specify your requirements when you first write to request access to your records, or in subsequent correspondence. In the case of a health authority, patient confidentiality dictates that only a healthcare professional can look through your notes, therefore you will be given a copy of your records in full and not in part.

Can I make an application on behalf of someone else?

Yes. You can apply for access to medical records of behalf of someone else in the following circumstances:
  • Where the patient is a child (under 18, or under 16 in Scotland), anyone with parental responsibility can apply for access to the records on the child's behalf. Where the child is capable of giving consent (ie is able to understand the nature of the application), access should only be given if he or she agrees. Where the child is not capable of understanding the nature of the application, access may be granted if this is in his or her best interests.
  • A patient may authorise another person to apply for access on his or her behalf. The person accessing the records must provide proof that he or she is acting on the patient's behalf (eg by providing a letter signed by the patient giving consent).

Can I get someone else to apply for my medical records?

Yes. If you would like someone else to apply on your behalf, you should write and sign a letter giving your consent for this.

Can I make an application on behalf of someone who has died?

Yes you can. If, however the record includes a note made at the patient's request that he/she did not wish access to be given to his personal representative or to any person having a claim arising from the death, you will be refused access. Access to information which is deemed not relevant will not be given. How do I go about gaining access to medical records of someone who has died? Once a person has died, he or she is removed from the GP's list and his or her medical records are passed to the health authority to keep. You should apply to the health authority in writing, addressing your letter to the Patient Services Manager or Medical Records Manager. You will be sent a form to complete with information to satisfy the health authority of your identity and that you are entitled to see the deceased person's records. You will also be requested to enclose a fee (see Sample application form in Appendix 2). How long does the health authority hold the medical records belonging to a deceased person? Medical records of a deceased person are held by the health authority for a minimum of 10 years and, depending upon the circumstances, up to 25 years.

What charges are there?

There is usually a charge to see or get a copy of your records. This charge is 10 if you just require information that is held in a computerised format but if there are also manual records it could be up to 50. You can find out the exact amount by ringing your surgery, hospital or health authority. Send a cheque or postal order for the amount with your written request. If you don't send payment it may mean you don't see your records. Yes, you may have to pay to see or get a copy of your records (or both). Photocopying charges vary according to how large your records are. You should find out how much this will be by ringing or writing to your doctor, hospital or health authority. You should then send a cheque or postal order for the amount with your written request. The maximum charges vary depending upon whether your records are held on computer or manually, and whether you would like a copy of your records or just want to see them. For access and copies* - records held totally on computer (10.00) - records held partly on computer and partly manual (a reasonable fee up to 50) - records held totally manually (a reasonable fee up to 50) *These fees are correct as at 12/00. Under the Data Protection Act 1998 'Subject Access', access is free if you don't need a permanent copy (i.e. a photocopy) if the information in your records has been added to in the last 40 days. If you want a copy of the information in your records there may be a charge per copy up to a maximum of 50. If your records have not been made or added to within the last 40 days prior to your application, you will be charged a fee of 10 plus a charge per copy and postage, if applicable. However if you make a request to view only there will be a fee of 10.

What if access is denied?

If you are denied access you have a number of courses of action. You can approach the Information Commissioner's Office if you think the organisation has breached the Data Protection Act by denying you access. Or you can complain through the NHS complaints procedure.

How long will it take?

You should receive a response promptly. You are entitled by law to receive a response no later than 40 days after your application was received. In exceptional circumstances, where this is not possible within this period, you should be advised accordingly.

If I want to see my medical records again, how long do I have to wait until I can re-apply?

If access to your medical records has been given, you do not have a right to see your records again until a 'reasonable' time has passed. What is a reasonable time will depend upon the type of records and how often they are changed.

How do I interpret information in them

You have the right to have any part of the records that you do not understand explained by the relevant Health Professional on written request. You should not be charged for the explanation.

What if something is wrong with the records?

If you think that your records are inaccurate ask the record holder to correct them. They must make amendments or attach a statement from you. If you disagree with what is written about you, You have the right to apply to the court to have it erased.

What do I do if I want to add information to my medical records?

You write to your surgery/hospital/health authority and apply for a note to be made in the records stating your opinion. In law, nothing can be erased from a health record but a correction may be added and a copy given to you.

Do I have to pay to add a note to my medical records?

No.

How long do I have to wait for my copy of the change?

You should receive a response within 21 days in the case of recently added information.

What if my records have been lost?

Unfortunately, this does happen from time to time. If your records were electronically stored, it should be possible to obtain a print out. If, however, manual records have been lost, it will not be possible to reconstruct your medical records.

If your request for access to medical records is part of a legal action you can ask what steps have been taken to recover your notes through an application to the courts.

How do I make a complaint?

Complaining via the Information Commissioner's Office You need to approach the Information Commissioner's Office and request an assessment form, which you need to complete. You can get a copy of the form by visiting their website or calling on their enquiry line: 01625 545 745 Send the completed form to the ICO with copies of any related document.

The health team of the Information Commissioner's Office may be able investigate to see if the act has been breached. They can contact the organisation that has denied you access to your medical records for an explanation. They will hear their version of events. It may be that the organisation is relying on proper exemptions to the act.

If your complaint is upheld then access to your records will be granted. If not, you will have to complain by other means. You could do it via the NHS complaints procedure. See also the iCan guide How to complain about private healthcare.

Complaining via the NHS complaints procedure To use the NHS complaints procedure you must be a patient or former patient of the practitioner or institution involved and you must complain within six months of the incident.

There are two important stages to the NHS complaints procedure:
  • Local resolution and conciliation with your local primary care trust
  • An independent review that considers your complaint
To find out exactly how to go through the NHS complaints procedure read the iCan guides, How to complain about NHS medical treatment in England, How to complain about NHS medical treatment in Scotland, How to complain about NHS medical treatment in Wales, How to complain about NHS medical treatment in Northern Ireland.

Complaining to the Health Service Ombudsman If you are denied an independent review, you can complain to the Health Service Ombudsman. The Health Service Ombudsman is independent of the government and the NHS. There is no charge for the service. The Ombudsman will not normally become involved unless you have already complained officially and are still unhappy.

How do I complain to the Ombudsman?

You should complain to the Ombudsman in writing. You can also use the complaints form available from the Ombudsman's office or on the website. Describe what happened in great detail and make sure you have copies of any relevant documents. The Ombudsman will only investigate if you have already suffered hardship or injustice. You must complain within a year of becoming aware of the events which you are complaining about. There is no appeal against the Ombudsman's decision.