top of page
  • Writer's pictureS. Minkina

NHS medical records - anything you may want to know

Granting patients a statutory right to access their medical records is relatively recent, and it is based on the Access to Medical Records Act of 1990, which entered into force on November 1, 1991. As a result of this law, patients could see their manual health records after that date and prior records, if necessary, to understand later ones.



There was no general statutory right to review handwritten records made before November 1991, although the NHS Board clearly stated that "access should be granted whenever possible". This Act still governs access to the medical records of a deceased person. As of March 1, 2000, the Data Protection Act 1998 (replacing the Data Protection Act 1984) entered into force. This law now allows access to all manual health records whenever they are executed, subject to certain exceptions. The Act also covers electronic and manual entries. This law applies to all living patients.


Other laws that affect patients' rights to access information about themselves are as follows.


Access to Personal File Act 1987, which deals with personal data held by local social services, could be relevant for shared custody.


1988 Access to Medical Reports Act For reports to employers and insurance companies


Do I have the right to see my medical records? Yes, you have the right to see your medical records under the Data Protection Act 1998.


There are some exceptions to this law. Here are the most important:


Access may be denied if healthcare professionals believe that the information on the file could cause serious harm to a patient or another person.

Details of third parties may be removed from the file.


If you are applying for access on behalf of someone else, you will not receive the information that the patient has given to their doctor, assuming it remains confidential.



Do I have the right to direct control of my data?


No, although this is allowed if the "data controller", usually a GP or physician, gives consent.


What's in your medical records?


Your medical records consist of files of notes, letters, charts, x-rays, test results, correspondence, etc., about the treatment you have received from the NHS during your life.


Why is it worth seeing?


There are many reasons why you may want to access your medical records.

  • You can make a complaint about how your healthcare is managed.

  • You can make a complaint about how someone else's healthcare is being managed, for example, a child for whom you have parental responsibility or a relative.

  • You may want to add new information to your medical records if you believe there are errors or inaccuracies.

  • You may have moved abroad and need to hand over your papers to a new doctor.

  • You can apply to stay in the United States and need your documentation for the application process.

  • You may want to find additional information about your healthcare.

  • Information in your medical records can help you find out more about what happened and confirm the details of the facts.



Do I have to provide a reason for requesting access?


No, unless you are seeking access to medical records for the purpose of legal proceedings (per the Protocol for Pre-Clinical Negligence Proceedings).




Where are my medical records collected?


Your GP keeps your medical records. Treatment notes received elsewhere, such as at a hospital, will be stored there. But your GP should also receive a summary report that will be added to your medical records. You can access records kept by other healthcare professionals, such as dentists and optometrists, by following the same procedure as your GP or hospital.


Who keeps my records if I don't have a GP?


Your records will be kept by the local health authority or the health board (in Scotland) whose medical list is on your last GP.


How long are they kept?


Hospital records

Hospital records are usually kept for at least eight years after treatment has ended, but there are many exceptions, e.g., Children and adolescents, maternity records, mental health records etc.


GP Records

GP records are usually kept for ten years after the end of treatment, death of the patient, or after the patient has permanently left the country, but there are many exceptions.


Who has access to them?


Effective October 24, 2001, the Data Protection Act 1988, "Subject Access", replaced the 1990 Act on Access to Medical Records, except in the case of a deceased person, while the 1990 Act on Access to Medical Records was still in force. Everyone has the right to access the personal data stored about him, in computerized or manual form, whenever the recording is made. This includes NHS medical records and private records prepared by doctors and other health professionals.

  • You.

  • Another person with your written consent.

  • Parent or guardian of a person under the age of 16, if the person agrees.

  • A court-appointed representative of a person who is unable to manage his own affairs.

In the event of the patient's death, the personal representatives and anyone with a claim arising from death may request an inspection of the file or parts thereof. The recorder is not required to disclose anything that is pre-November 1991.


Why might access be denied?

There are some exceptions:

  • Access may be denied if healthcare professionals believe that the information on the file could cause serious harm to a patient or another person

  • Details of third parties may be removed from the file.

If you are applying for access on behalf of someone else, you will need their consent or authorization.

  • when a healthcare professional believes that access could seriously harm you or anyone else.

  • when the record contains details that the patient has asked not to be disclosed to third parties.

  • disclosing the data would reveal information that relates to or identifies another person unless he gives his consent, except where it is reasonable to disclose the documentation without that person's consent.

  • when it is not possible to provide a copy of the requested information (because, for example, the data has been destroyed in accordance with the HSC 1999/053 guidelines).


What are the other healthcare documents?


You can access medical records kept by healthcare professionals other than GPs and hospital doctors, for example, dentists and optometrists, who follow the same procedures as a GP or hospital.


What is the procedure for accessing them?


You can make an informal request to have your medical records checked. You can do this during a consultation, call an office or hospital, arrange an appointment, and review the documentation. You can make a formal request to review the documentation that needs to be entered. Your doctor or hospital may give you a form to complete instead of writing a letter. Be sure to keep a copy of all correspondence. Each practice or hospital is different and will affect whether you start with an informal application or make a formal application first.


Request access informally


The first step should be to ask your GP or health office if you can examine them directly, although this is not appropriate. You can also call a clinic or hospital and make an appointment.


Request formal access


You can also make a formal request for access to your medical records in writing. If the documents are kept at a doctor's office, you should write directly to your doctor or office manager. The Information Commission recommends that you send the letter by registered mail. If records are kept in a hospital, address the letter to the hospital's patient service manager or medical records officer. It is worth asking if there is a form that can be completed.


The advantage of submitting a request in writing is that you are legally entitled to receive a reply no later than 40 days after receiving the request.


Proof of Identity: You may be asked to show proof of identity if you request to see your medical records at locations other than your GP. You must request the appropriate form and have a witness sign to prove your identity.


Tips

  • Be persistent but always polite.

  • It is worth talking to the head of the surgery office. Different operations have different systems.

  • Be prepared to chase a GP or hospital if you feel the process is taking longer than expected.


  • Always keep a record of all data from the file.

  • Contact the Patient Association if you need expert advice on accessing the NHS Complaints Procedure.

Who should I write to?


If the documents you want to see are kept at your doctor's office, you should write directly to your doctor or the office manager. If the records you want to see are kept in a hospital, you should send a letter to the Head of the Health Registry at the hospital's address. If you want to see the documentation at the health office, you should address the letter to the Patient Service Manager or Medical Records Officer.


What are the advantages of formally submitting an application?


If you submit your request informally, you are under no legal obligation to receive a reply. However, if you submit your request in writing, you are legally entitled to receive a response no later than 40 days after receiving the request. In exceptional circumstances, when this is not possible within this period, you should be informed accordingly.


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


Yes, After the first letter asking you to check your medical records, you will be sent an application form or request for personal identification, usually a signature verifying your identity from someone else who knows you. If you are applying to your GP or hospital, this may not be necessary. If you are applying to a health office, you will need to do so. Make a request in writing to the person who has your records to request access to see it. Ask a healthcare professional during a consultation or during hospitalization to show and, if necessary, explain the current segment of care to you. You will need the patients' written consent if you want to check their record. If you want to see records of a patient who has died, you must either be a personal legal representative or the person whose legal claims are based on the death. If you require a copy of the records or a written explanation of the information therein, you must submit a written request to the person who keeps your records. You will be prompted to fill out a form for this purpose. You may need to provide proof of identity. It may be possible to show the records immediately upon request. (Only if the consultant is able to sit down with the patient, and only then these notes directly relating to the consultant's specialization.) If not, an appointment will be made upon request to view them. If you have requested copies in writing, they will be sent against payment of the appropriate fee. You may not want copies of all your records. The record-holder will ask you to identify which parts you want to save time and money.


How long should I wait for my appointment to review my medical records?


This is not specified, but if you believe your request is not being dealt with promptly and that you are giving in to unreasonable expectations, call your practice/hospital/health care provider and ask for the reason for the delay. If your needs are still not being met, you can consider making a complaint.


Can I make an application on behalf of someone else?


Yes. You may apply for access to medical records on behalf of someone else in the following circumstances:

  • If the patient is a child (under 18 or 16 in Scotland), any person with parental responsibility may apply for access to the file on behalf of the child.

  • If the child is able to give consent (i.e., can understand the nature of the request), access should only be granted with the child's consent.

  • If the child is unable to understand the nature of the request, access may be granted if it is in their best interests.

  • A patient can authorize another person to request access on their behalf.


The person accessing the records must provide evidence that they are acting on behalf of the patient (e.g. by providing a letter signed by the patient giving consent).


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


Yes. If you want someone to make a request on your behalf, you should write and sign a letter giving your consent.


Can I make a claim on behalf of a deceased person?


Yes, you can. However, if the records contain a note at the patient's request that he/she does not wish to have access to his / her personal representative or any person with a death claim, you will be denied access. Access to information deemed irrelevant will not be granted.

How can I access the medical records of a deceased?


Upon death, the person is removed from the GP's list, and their medical records are submitted to the health office for preservation. You should submit a written request to the health authority by addressing your letter to the patient services manager or medical records manager.

You will receive a form to be completed with information confirming the identity of the Health Authority and that you are entitled to see the deceased person's file. You will also be asked to attach a fee. How long does the Health Authority keep the medical records of the deceased? The medical records of a deceased person are kept by the health authority for at least ten years and up to 25 years, depending on the circumstances.


What are the fees?


As of May 25, 2018, in most cases, patients must access their medical records as a Subject Data Access Request (SAR) free of charge, including when the patient allows access to third parties such as an attorney. If your request is for the creation of a medical report or the interpretation of information contained in a medical report/records, this will be governed by the Medical Report Access Act (AMRA) - as both require the creation of new data that is outside the scope of the GDPR and entity access requests. In such cases, a fee may be charged. The medical report/records that already exist will be available free of charge as SAR. A "SAR" may be charged a "reasonable fee" if the request is manifestly unfounded or excessive, but these circumstances may be rare.


What happens if access is denied?


If you are denied access, you have many options for action. You can approach the Information Commissioner's office if you believe the organization has breached the Data Protection Act by denying you access. Or you can make a complaint through the NHS Complaints Procedure.


How long will it take?


You should get a reply promptly. By law, you have the right to receive a reply no later than 40 days after receiving the request. In exceptional circumstances, when it is not possible within this period, you should be informed about this fact.


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


If your medical records have been accessed, you are not allowed to review them again until a “reasonable” time has elapsed. Reasonable timing will depend on the type of records and how often they are changed.


How to interpret the information they contain?


You have the right to receive any part of the documentation that you do not understand explained by the appropriate health professional upon written request. You shouldn't pay for an explanation.


What if there are errors in the report?


If you believe that your data is inaccurate, please ask the data controller to correct it. He must make changes or attach a declaration. If you do not agree with what is written about you, you have the right to ask the court to remove them.


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


Write to your practice (GP0 / hospital / health office and request a file note with the opinion. By law, nothing can be removed from the health record, but you can add an amendment and get a copy.


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


No.


How long will I have to wait for the change to take effect and receive a copy?


For recently added information, you should receive a reply within 21 days.


What if my records are lost?


Unfortunately, it does happen from time to time. If your records have been stored electronically, it should be possible to obtain a printout. However, if you lose your manual records, you won't be able to restore your medical records.


If your request for access to medical records is part of a legal proceeding, you may ask what steps have been taken to recover your records by filing a motion with the court.



 

42 views0 comments

Recent Posts

See All

Comments


bottom of page