Access To Medical Records

Your Personal Health Information

files_1 To provide you with the care you need, we hold the details of your consultations, illnesses, tests, prescriptions and other treatments that have been recorded by everyone involved in your care and treatment e.g. G.P, Health Visitor, Practice nurse.

This information may be stored on paper or electronically on computer files by practice staff.  We sometimes disclose some of your personal health information with other organisations involved in your care.  For example, when your GP refers you to a specialist at the hospital. Our practice also participates in regional and national programmes such as the cervical cytology screening service and your name and address, date of birth and health number will be given to them in order to send an invitation to you.

We need to use some of your personal health information for administrative purposes. In order to receive payment for services provided to you, we have to disclose basic details about you to the NHS Board responsible for this area.  These organisations have a role in protecting public funds, and are authorised to check that payments are being properly made. We are required to co-operate with these checks and the disclosure of your data is necessary part of our provision of healthcare services.

Sometimes, we may participate in studies that are designed to improve the way services are provided to you or to check that our performance meets required standards and benchmarks. 

Whenever we take part in activities such as these we will ensure that as far as possible any details that may identify you are not disclosed.

We are involved in health research and the teaching of student nurses, doctors and other health professionals. We will not use or disclose your personal health information for these purposes unless you have been informed beforehand.

Sometimes we are required by law to pass on information e.g. the notification of births and deaths and certain diseases or crimes to the government is a legal requirement.

Our use of your personal health information is covered by a duty of confidentiality, and is regulated by the Data Protection Act. 

Everyone working for the NHS has a legal duty to keep information about you confidential and adheres to a Code of Practice on Protecting Patient confidentiality.

Accessing Your Medical Records

In March 2000, the Data Protection Act, 1998, replaced the Access to Health Records Act legislation.  This gives people the right to see all information kept about them by any organisation.  Under the Data Protection Act, patient’s can now see their health records from the day they were born.

A request can be made by:

  • Parent or person with parental responsibility (A parent can only do this with child’s consent) – proof of parental responsibility will be required if child lives at a different address.
  • Someone who cannot manage their affairs and where a person authorised in writing makes the application.
  • In the case of a deceased patient, the patient’s personal representative or any other person who may have a claim arising from the person’s death1
  • Court appointed representative

Patients have access to their written and computer records if requested, although the records may not be removed from the practice premises.

Assistance is given by the Practice Manager if access is required to the computer record and in this circumstance a member of staff will stay with the patient at all times.

How to access your records:

  • Contact the Practice Manager in writing with your request.You will be able to view and/or have copies of your health records within 40 days of your request being made.
  • No charge can be made to view information recorded within 40 days of an entry having been made to the record.  A £10.00 fee where access is requested to records and no entry has been made within the previous 40 days.  Charges may be made for photocopies and copies of x-rays up to a maximum of £50.00 including the access fee.

Refusal of request to see medical records:

The GP can refuse that you see the health record if they feel it would cause serious harm to the physical or mental health of the patient.  The patient has the right to be advised about this refusal.

If you think your health record is wrong:

You may ask for it to be corrected.

If the health professional believes the information to be accurate then a note will be added indicating you disagree.  If the health professional refuses to make a necessary correction a complaint can be made to the Health Service Commissioner.

For patients who have died, the Access to Health Records Act, 1991, still applies and records are only available from November 1991 onwards.  A fee of £10 charge for access to records is still applicable.

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