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.
What is a medical record?
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.
What does my medical record contain?
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:
- Laboratory reports
- Prescription charts
- Phone call recordings
- Notes on the patient’s condition
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:
- All of your recorded illnesses and allergies, if any.
- Any side effects you may have had from medications you’ve taken in the past
- Currently prescribed medications, such as blood pressure or cholesterol medication, or asthma inhalers taken regularly.
- A list of all of the medications that have been prescribed to you in the last 6-12 months
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.
Are my medical records private?
How long do hospitals keep my records?
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.
Mental health 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.
Who can access my summary care record?
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.
Who owns patient medical records in the UK?
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.
- Any organisation with which the NHS engages to process data is generally referred to as a data processor.
- Any organisation with which the NHS engages to collect data is generally referred to as a data controller.
How can I view my personal medical records?
You can use the following methods to access your medical records
Inquire with the service
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.
Subject access requests
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:
- First and last name
- Permanent address
- Date of birth
- Any other information that might be useful in locating your file
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.
Is it possible for my request to be denied?
The following situations may result in your request to ‘see my records’.
- A health practitioner believes that accessing your medical information might be detrimental to your physical or emotional health in the long run.
- The records also have a connection to another individual.
How do I get my medical records from childhood in the uk?
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.
When can I receive my 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.
How much does it cost to get your medical records?
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.
Can someone access my medical records without my permission?
Your medical data is held strictly private. No one else is permitted to see your medical records unless they:
- A healthcare practitioner relevant to your case
- Have your signed consent
- Have the legal authority to manage your interests
Can I see my relative’s records when they die?
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.
Personal representatives and claimants
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:
- Reason for your request for information.
- The opinions of any surviving family members.
- If there is somebody who will be affected if the records are revealed.
- Whether you had a personal connection to the individual who passed away.
- Whether the individual who died specified whether or not they wanted their records shared.
- How long ago the person passed away.
- How much information you are requesting.
Can doctors withhold medical records?
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.
Can doctors’ receptionists access medical records?
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.
Who else can see my medical records?
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.
Сan I request a copy of my medical records?
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.
What if the information on my record is wrong?
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:
- When you see a doctor, they will add your illness and treatment information to your medical record.
- You can have a “summary care record” that tells the NHS important things about your health. You can get one for free.
- You can access and get a copy of your record. But your doctor can keep some things from you if they could hurt your physical or mental health.
- Other people, like your boss or insurance company, can only see your records if you want them to.
- You should be able to obtain a copy of your record within one month.
- You can’t easily delete something from your records that you find incorrect. Your GP can add a note to show you disagree.
- The “Patient Online” service should let you see your records online if you sign up for it.