Accessing Medical Records
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Medical records in the NHS are the property of the Secretary of State for Health and are governed by the Data Protection Act. Most NHS Trusts are now working towards a single patient record, which will eventually be stored electronically. A single patient record means that there is one set of notes where every professional, including students, who looks after a patient will make notes in a single, consecutive record which is signed, dated and sometimes timed after each entry. Some Trusts still allow each profession to keep their own notes and these are then brought together in a single file once the patient has been discharged.
The confidentiality and use of patient records is the responsibility within each Trust of a senior manager known as the Caldicott Guardian.
Who can access Medical Records?
Patients and/or their next of kin or representative can request access to their medical records under the Data Protection Act. This request can be refused if the consultant in charge of the individual's care believes that sight of the medical records will be detrimental to the patient's mental health. Otherwise, records can be released, but will not include what is known as "third party information" i.e. information supplied by someone outside the NHS Trust e.g. GP, social services, identified individuals, without the written permission of that third party. Bodies can also refuse to disclose information which contains confidential information about a third party e.g. another patient. If records are requested by a legal representative, third party information will normally be included within the records and any identified gaps in records can be re-requested and must be provided within a designated timescale.
What should I expect to be included in my Medical Records?
Medical professionals are now discouraged from writing anything other than factual information within medical records. In the past, it was common for doctors to write comments and personal perspectives about patients within notes, which were often derogatory. The General Medical Council and the Nursing and Midwifery Council encourage practitioners to write clear, concise, factual and contemporaneous notes. Some Trusts now undertake periodic audits to check the quality of patient notes and omissions and bad practice are identified so that appropriate action and training can be instigated.
If inaccuracies and/or omissions are subsequently identified by patients and their representatives within medical records, a request can be made for a note to be placed within the records with the appropriate correction. It is unusual for medical records to be deliberately falsified; usually inaccuracies and omissions are the results of poor record keeping practice. Falsifying records is not a criminal act, but can be considered under fitness to practice procedures or gross professional misconduct.
How to access your records
When formally contacting your NHS Trust or GP surgery it is useful to keep a copy of your request. If sending a letter it is a good idea to send this recorded delivery and if using e-mail, request a delivery message or an acknowledgement of safe receipt.
Your should state clearly in your letter, fax, or e-mail that you want the information that you are entitled to under the Data Protection Act 1998. It would also be useful to provide as much information which would help locate your records, i.e. who your treating surgeon/GP is, your address and your NHS number.
You should receive a reply to your request within 40 days. You may be asked to send a fee for the reproduction and postage of the records, which can vary, and you will also need to prove your identity. The cost of providing your records should not exceed £50.
Information about accessing medical records can be found on www.informationcommissioner.gov.uk Help in accessing medical records can be obtained from the Independent Complaints Advocacy Services (ICAS).
Talk to an expert about making a claim
Call us on 0870 024 0558 or fill in our claim form and we will get back to you.