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Accessing your Medical Records

 

Thyroid UK always suggests that people keep a note of their test results so that they can see the full picture of their thyroid health.  The NHS Constitution contains a right for patients to access their health records, which is covered by the Data Protection Act 1998.

You have the right of access to your own health records. These will always be used to manage your treatment in your best interests”

paper medical record storeSome people can access their medical records online now and the plan is to make all medical records available online in the future.  However, if this option is not available to you, you may need to ask your doctor for access to your medical records to get copies of your test results.

You can simply ask your doctor, during a consultation, to view your records and write them down or ask for a copy of your results and, in most cases, doctors are willing to allow this without any problem and free of charge.  Alternatively, you can telephone your GP surgery or hospital to arrange a time to see your records and then you can make a note of your results. There may be a fee to access your health records (see below).  However, sometimes, doctor’s receptionists or the doctors themselves are not very helpful in this respect.

So, what are your rights in respect of your health records?  First of all, you need to be aware that your health records means any record of information relating to your physical or mental health that has been made by, or on behalf of, a health professional.

For the purpose of the Data Protection Act, a registered health professional can be one of the following people:

  • A medical practitioner - this could be a GP, consultant or hospital doctor
  • A dentist
  • An optician
  • A pharmaceutical chemist
  • A nurse, midwife or health visitor
  • An osteopath
  • A chiropractor
  • A clinical psychologist, child psychotherapist or speech therapist
  • A music therapist
  • A scientist employed by a health service body as head of department
  • Anyone registered as a member of a profession to which the Health Professionals Order 2001 for the time being extends

If you are refused access to your medical records by your doctor, then you may need to make what is called a “subject access request” (SAR). A subject access request is simply a letter or email to the relevant person which will depend on which health records you want to see - your GP surgery, your optician, your dentist or the hospital trust's health records manager or patient services manager.

It’s a good idea to find out which department and person you need to send the request to and to make sure you know exactly which information you want as a fee can be charged for every request – if you forget something, you may have to pay again. 

The person who deals with the requests will then decide whether your request can be approved. They can refuse your request if, for example, they believe that releasing the information may cause serious harm to your physical or mental health or that of another person.

Under the Data Protection Act, requests for access to records should be dealt with within 40 days although Government guidance for healthcare organisations says they should aim to respond within 21 days.

When requesting your personal information from an organisation, make sure you include the following information:

  • your full name, address and contact telephone number
  • details of the specific information you require and any relevant data i.e. your medical records (between 2006 & 2009) held by Dr ‘A’ at ‘B’ hospital

Although you may be asked why you want to access your health records, there is no obligation for you to tell them.

 

Do I Have to Pay for Accessing my Records?

You can access your health records free of charge if:digital medical records

  • The records have been updated in the previous 40 days and
  • You don’t require a copy.

If the records have not been updated in the last 40 days and you don’t require a copy, the maximum charge is £10. This charge applies whether the records are stored:

  • on computer
  • partly on computer and partly in another form, for example, paper records such as letters or hand-written clinical notes, or images such as X-ray film
  • entirely in another form

If you do want a copy, the maximum £10 charge for viewing will be included in the fee for obtaining a copy (see below). You will not be charged twice for one access request.
If you want a copy of the health records, the fee will depend on how the records are stored:

  • on computer: maximum £10
  • partly on computer and partly in another form: maximum £50
  • entirely in another form: maximum £50

If you request your information to be sent to you in the post, the maximum charges include postage and packaging.

 

Accessing Health Records of Someone Who has Died

The fees for accessing the health records of someone who has died are slightly different. For more information go to:
www.nhs.uk/chq/Pages/access-to-medical-or-health-records-of-someone-who-has-died.aspx

 

Accessing Health Records of Someone Else

To access someone else’s health records, you must:

  • be acting on their behalf with their consent, or
  • have legal authority to make decisions on their behalf (power of attorney), or
  • have another legal basis for access

Parents can make an SAR on behalf of children under the age of 12.  A child over the age of 12 can make their own request and you would therefore need to get their consent to make an SAR.  You must use your judgement to decide whether a young person aged 12 or above is mature enough to make their own request as they do not always have the maturity to do so.

There are specific rules for applying for access to someone else’s records and these rules apply if you would like someone else to access your records.

For more information go to:
www.nhs.uk/chq/Pages/access-to-someone-elses-medical-or-health-records.aspx

 

Has your Access Request been Poorly Dealt With?

ICO logoIf you are unhappy about the way your request for accessing your health records has been treated you should initially complain to your healthcare professional.
If you are still unhappy, you can make a complaint to the Information Commissioner’s Office.

For more information go to:  https://ico.org.uk/concerns/getting/

 

Last updated 31/3/2015