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
No, although it is permitted if the 'data controller', usually your General Practitioner (GP) or the health authority, agrees.
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.
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.
No, unless you are seeking access to medical records with a view to commencing legal proceedings (pursuant to the Clinical Negligence Pre-action Protocol).
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.
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.
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 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.
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.
- 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.
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).
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.
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 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.
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.
- 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
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.
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.
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.
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
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.
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).
Yes. If you would like someone else to apply on your behalf,
you should write and sign a letter giving your consent
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.
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.
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.
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 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.
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.
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.
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.
You should receive a response within 21 days in the case of
recently added information.
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.
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.
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.