As a valuable resource for the NHS, the 67 million medical GP records across the country have been named “the NHS’s greatest asset.” Every diagnosis and treatment a person has ever had is documented in this massive database. It is invaluable information for tracking sickness and improving healthcare quality.
Our medical records are, without a doubt, some of the most private and sensitive documents that we have, and they accompany us throughout life. They not only contain information about our medical histories, but they also contain information about our personal lives, financial situations, and our private address.
In this post, we’ll address the most often asked queries about medical records, placing you in a better position to maintain your private medical information security.
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Any information about your physical or mental health that a healthcare provider has documented is included in your medical records. This includes GP records and any information recorded by health workers. It may also include health records that are stored by your workplace. These records may be stored on a computer or written by hand.
If you are a GP’s patient in England, information about your medical history is recorded in an electronic medical record. This is referred to as a Summary Care Record (SCR). The only individuals who will have access at this time will be those who work at your local NHS GP practice.
The National Health Service (NHS) retains detailed data locally so that the person in charge of your treatment may access them. This implies that your GP surgery will record all of your GP appointments. Your mental health team will keep track of your interactions and all of your appointments with them.
Your medical records contain information about items such as your diagnosis, reports, letters, and test results, among other things. The following are some examples of the kind of information that could be included in the document:
Your SCR contains information such as your name, address, date of birth, and a unique NHS number that can be used to identify you. On top of that, it includes the following:
Patients on the NHS can also include additional information in their SCR if they like. This could include information on long-term conditions: immunisations received, or your choices, such as information about end-of-life care or specific care needs, and other relevant information. This additional information will only be included if you and your GP believe it is required. This is something you should address with your doctor.
Yes. Your medical information is kept strictly private. The National Health Service should not disclose your health details to anyone without your permission.
Every time you visit an NHS facility, a record of your treatment is created. Depending on the provider, your records will be kept for a varying amount of time. The length of time a record is kept is determined by where it is kept.
Normally, records are preserved for up to 8 years after you were last seen by the service or released. These are referred to as “adult health records.” There are a few exceptions, which will be discussed below.
When you first visit your doctor’s office, they will make a record of your visit. As long as you are still registered there, this information will be maintained and updated. Your GP records will typically be preserved for ten years after your death.
Electronic patient records are available at some NHS facilities and general practitioners’ offices. The record should be destroyed at the end of the period, which is pre-determined. Also, individuals utilising the computer system should not access your medical records.
These include information about any treatment you may have had under the Mental Health Act 1983. This covers people committed to a mental health facility under the Mental Health Act.
Your records will be preserved for 20 years following the date you were last seen or released from the Act. Alternatively, your records will be kept for eight years if you die.
Maternity Records are kept for 25 years after the birth of the final child. Children’s and youngsters’ records are kept until the patient reaches the age of 25 or eight years after their death, whichever comes first.
Access to your SCR will be restricted to authorised healthcare professionals in the UK who are involved in your direct care and who require information to conduct their jobs. Health professionals will ask for your permission before looking at your SCR, and you will be informed if they do so.
If they cannot contact you because you are unconscious or otherwise unable to interact, they may decide to look at your record because doing so is in your best interests.
Anyone who has access to your information must utilise a swipe card system, automatically logged and centrally monitored to ensure that the access is appropriate and secure. Each practice has a privacy officer in charge of keeping track of who has access to what information. Other agencies will not be able to access your SCR information.
In terms of legality, there isn’t such a thing as “owning the records.” Under the terms of UK data protection law, you can be a data controller, a data processor, or a data subject, which is the individual about whom the data are being collected.
You can use the following methods to access your medical records
Under the General Data Protection Regulations(GDPR), you have the right to check your medical records. If they reject, you could try submitting a ‘subject access request’ to the appropriate authorities. This has been detailed further below.
While at an appointment or over the telephone, you could request to see your records. If they accept, this is a quick and simple method of accessing your records. They could hand you a piece of paper or show you the notes on a computer screen. However, they may not be able to provide you with a copy of your records in this manner. You may need to submit a subject access request to obtain a copy, or your local NHS trust can provide you with information on how to do so.
Under Article 15 of the General Data Protection Regulations (GDPR)., you have the right to request a copy of your medical data, which you can use to your advantage. This is referred as to as submitting a subject access request.
You can submit a subject access request either in writing or by talking with a representative from the service. It’s possible that the service will have a form that you must fill out.
A PALS (Patient Advice and Liaison Service) in your area may be able to assist you with a subject access request. Please include the following information in your request:
Inform them that you will be submitting a subject access request under Article 15 of the General Data Protection Regulations (GDPR). You are not required to provide the provider with a reason for your request to view your records. However, you may be required to provide them with some form of identification.
When requesting access to your records, you are not required to complete a particular form. However, certain services may require one to expedite the procedure. If you are doubtful, consult with the service first. If possible, you should send your letter or form by registered mail or certified mail.
The following situations may result in your request to ‘see my records’.
A request to see the records must be made to the entity with your health records – the data controller – For example, your GP’s office, paediatrician, or dentist.
Contact the records manager or patient services manager at the respective hospital trust for information about hospital health records.
The National Health Service (NHS) has one calendar month to send your information. This can be extended for an additional two months if you have made several requests or if the information you have requested is extremely complex.
The National Health Service (NHS) strives to respond to inquiries within 21 days.
A copy of your data can be availed of without a fee under the General Data Protection Regulations (GDPR) unless you request a very significant amount of information or you request information that you already had.
Your medical data is held strictly private. No one else is permitted to see your medical records unless they:
Even after someone passes away, their medical records remain confidential. The following people can only access them. If you are granted access to your medical records, you will not be charged for them in any way.
You could be a personal representative or have a claim arising from the death of another party. You have the right to request to inspect the person’s medical records.
Being a personal representative for someone implies you are responsible for their affairs after they have passed away. This includes dealing with their real estate and bank accounts, among other things.
People entitled to inheritance can be included in those who have a claim arising from someone else’s death, although the law is uncertain on what constitutes a claim.
You must contact the record holder and provide sufficient information to identify the records. Proof that verifies that you are the estate’s personal representative or that you have a claim should be included with your submission. You may be required to submit documentation such as a death certificate, a grant of representation, or a copy of the will. You may be asked to provide identification as well.
If the individual placed a notation in their records stating that they did not wish to be seen by you, the NHS might refuse to allow you to see them.
If you do not fall into one of the categories listed above, you can still request to see someone’s medical records. It will be up to the NHS to determine whether or not they will disclose your records with you. They should consider the following:
According to the Data Protection Act, the NHS has the right to withhold information that could cause substantial harm to your physical or mental health or the health of others. The person in charge of the records should explain why they decided to withhold information from you.
Your records may contain information about other people. The National Health Service (NHS) should seek their permission before sharing this information with you. If the individual does not consent, the NHS may refuse to provide you with this information. If the NHS cannot obtain their permission, it will have to determine whether or not to share this information with you. They will make this decision on a case-by-case basis.
Your confidential appointments are never discussed with the receptionists. They do indeed have access to your medical records to type letters, file and scan incoming hospital letters, and carry out various other administrative tasks. They are not permitted to use your data for any other purpose than those stated above. They are also prohibited from discussing any information about patients outside the workplace. This would be considered a dismissible offence.
Staff members at the hospital are only permitted to access your data if they have a legitimate purpose for doing so; they are not permitted to look at your record without a valid reason. Their access to your information is limited to only the information they require to do their duties and assist you in managing your health.
Yes, you can request copies for yourself. An application form, which is usually available on the Trust or GP website, will assist you in requesting a copy of your records. The form will also explain what information and documentation they require to supply you with a copy. The information you seek is normally delivered without a fee. However, there may be a charge in some situations.
Your records should be up to date and accurate. Certain information included in the record is based on professional opinions. The NHS won’t normally erase these comments. They must maintain this information since it explains their decisions concerning your care.
Unless it is factually inaccurate, the NHS will not erase or remove information from your records. This could include an incorrect address or birthdate.
If your doctor agrees that the information is incorrect, they can help you correct it. If your doctor disagrees, you should be able to add a note. You can send a letter to the record holder and express your concerns.
Here are the basics about medical records to keep in mind:
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