Accessing your medical records

What are your medical records?

Photograph of a stack of papers entitled 'Medical Records'A medical record contains information about your mental and physical health, recorded by a healthcare professional as part of your care.

Your record will include:

  • GP and hospital doctor records
  • Nursing records, and those made by other NHS staff
  • Records of visits to you and your visits to the hospital, practice or clinic.
  • Details of treatment, medication, tests and their results, diagnosis, referrals etc.

Your rights

All NHS staff have a duty of confidentiality towards all patients and their records. Under the Data Protection Act 1998 you have a right to see your medical records. You don’t need to give a reason why you are making the request and your records will be provided to you unless:

  • Your doctor thinks that to do so would seriously harm you or another person.  (This refusal can apply to part of your records. You are not automatically informed if some of your records have been withheld, therefore it is worth asking if all of your records have been provided.)
  • Providing the records would involve “disproportionate effort” on the part of a Trust of GP Practice.  (“Disproportionate effect” has not been defined, but the Data Protection Information Commissioner has warned against abusing this reason to block access to your medical records)

 

How to apply for your records

You must submit a request to see your medical records in writing or by email to a registered health profession including:

  • Your GP surgery
  • Your Optician
  • Your Dentist
  • Your Hospital Trust ( address the request to the Health Records Manager or Patient Services Manager)

This is known as a Subject Access Request (SAR).

In your request, it is helpful to provide the dates of the records you want to see and ask if there is a charge.

Most NHS Trusts and GP practices have a form specifically designed for a medical records request which you may be asked to fill in.

 

What happens next?

Once you have made your request, the healthcare professional will decide whether your request can be approved. Records should be made available to you within 40 days of your application, or 21 days if they have been added to within the last 40 days.

You may be charged a fee to see your medical records if they have not been added to within the last 40 days, but this charge should not be more than £10.

If you want copies of your records, you will be charged the actual cost for photocopying and postage up to a maximum of £50. If you are making a complaint, it is useful to get copies of records if you need to use them as evidence.

 

What do I do if my records are wrong?

Information Commissioner's Office ICO logoYou can ask for your records to be corrected if you think they are inaccurate. If the Trust, or medical practitioner disagrees with the changes you want to make, you can ask for a note to be attached to your records recording the disagreement. If you have a complaint about inaccuracies contained in your records, you can contact the Data Protection Information Commissioner at the following address:

Head Office-Information Commissioner’s Office
Wycliffe House Water Lane
Wilmslow
Cheshire
SK9 5AF

Tel: 0303 123 1113

www.ico.org.uk

You can find template letters on how to request your medical records and also how to challenge inaccurate information contained in your medical records on the ICO website.

 

Can I view the medical records of a deceased person?

Records can only be obtained by a Personal Representative (usually an Executor) or someone making a claim arising from the death, unless the deceased specifically requested in their records that they did not want that person to have access to their records.


Contact our NHS complaints advocacy team

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Accessing your medical records
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If you would like to talk to the Healthwatch Bury advocate, or if you would like support with a complaint about the NHS and you live in Bury contact us:0161 253 6300

advocacy@healthwatchbury.co.uk

Our office is open between 9.30am -4pm Monday – Friday.

Outside of these times an answerphone service is available.


guides to making complaints about health and social care