What is a health record?
A health record consists of information relating to your physical or mental health. The record may be made by, or on behalf of, a health professional in connection with your care.
Who can apply to see a health record?
- You as the patient
- A person authorised by you in writing to apply on your behalf
- A person having parental responsibility if the patient is under 18 years of age
- A person appointed by the court to manage the affairs of a patient
Can I apply to see the health records of someone who has died?
Yes, an application to access the record of a deceased person is governed by the Access to Health Records Act 1990. Under this legislation, the personal representative, executor or administrator or anyone having a claim resulting from the death (this could be a relative or another person), has the right to apply for access to the deceased’s health record. You will not be given information that the person gave in the understanding that it would remain confidential. Access to information which is considered not to be relevant will not be given.
What does access encompass?
- The right to obtain a copy of the record in permanent form
- The right to view a record without obtaining a copy
- The right to have information explained where necessary, e.g. medical abbreviations and terminology
Will I be charged for the service?
The Trust is under no obligation to comply with requests for access to health records until we receive a completed ‘Application for Access to Health Records’ form providing such further information as the Trust may require to sufficiently identify the data subject, proof of identity and their address. A copy of the record will be provided free of charge, however a fee is charged if you wish to receive further copies of the same information.
There is no fee for requests dealt with under the Access to Health Records Act 1990.
- There is no fee if you want to view and/or receive one copy of your medical records including x-rays.
- Additional copies of the same information will be charged at £10 per copy.
Can access be refused?
There are several circumstances under which access may be denied or restricted, however, the two most relevant to healthcare are:
- If the record contains third party information where that third party is not a health care professional and has not consented to their information being disclosed. If possible the individual should be provided with access to that part of the record which does not contain the third party identifier
- If access to all or part of the record will seriously harm the physical or mental well-being of the individual or any other person. If possible the individual should be provided with access to that part of the record that does not pose the risk of serious harm
What happens if I want to view my health record while I am an inpatient?
Discuss this with your doctor who may be able to help immediately or ask for an application form.
How do I request access to my records?
An ‘Access to Health Records’ application form can be accessed online or obtained from:
The Access to Health Records Officer
Royal National Orthopaedic Hospital NHS Trust,
Brockley Hill, Stanmore, Middlesex, HA7 4LP
Tel: 0208 909 5366
Once you have returned the form to the Access to Health Records Officer, we will confirm we have received it and give you an explanation of what will happen next. It is important that you give as much information as possible about the records you want, so that your application is not delayed. You should receive a copy of your records within 30 days after we have received your completed application form, proof of identity and your address, confirmation of the information you require, how you want to receive the information, and payment of the required fee if you require more than one copy of the same information. We will keep you informed if it is likely to take longer.
OTHER USEFUL INFORMATION
What to do if you do not understand something in your health records
You have a right to have any part of the record that you do not understand explained by the relevant health professional upon written request to the Access to Health Records Officer. You will not be charged for this explanation.
What to do if access is refused
If you feel that the refusal is unjustified you may wish to consider making a formal complaint to the Trust’s Data Protection Officer. Alternatively you can approach the Trust’s PALS service to see if they can offer further advice. You may also seek advice from the Information Commissioner.
Post: Information Commissioner's Office
Tel: 0303 123 1113
What to do if you feel there are mistakes or inaccuracies in your health record
If you consider that there are mistakes or inaccuracies within your health records, you can ask the holder for a note to be made in the records stating your opinion. It should be understood that, for legal reasons, nothing can be erased from a health record but a correction may be added and a copy given to you.
If you have a complaint about the accuracy of the information that you are shown, or you think that parts of the records are being unnecessarily withheld, you can discuss this in the first instance with the relevant health professional. Alternatively, formal complaints may be submitted for further investigation to the Trust’s Patient Advice and Liaison Service Manager under the NHS Complaints Procedure.
You have the right to lodge a complaint with the Information Commissioner’s Office, details above.