Accessibility

Access to your health records

Access to your health records

The Data Protection Act 1998 gives every living person the right to apply for access to information held on them by an organisation.  This is known as ‘Subject Access’.

Health records

A health record is defined as a record consisting of information about the physical or mental health or condition of an individual made by or on behalf of a health professional in connection with the care of that individual. It can be in computerised or manual form (or both) and may include such things as hand written notes, letters, lab reports, x-rays etc.

Receipt of an application

All requests for access to health records are dealt with under a legal requirement.  These requests are dealt with by different departments within the organisation depending on the type of application:

If the application is from an individual or their representative where NO Litigation against this Trust is indicated – This application is dealt with by the Medico-Legal Officer, Medical Records Department.

If the application is from an individual or their representative where Litigation against this Trust is indicated – this application is dealt with by the Legal Services Team.

Applications for x-rays are dealt with by the X-ray Department.

The application

All applications to see health records must be made on the Trust’s Access to Health Records Form. 

(Please click here to download the form.) These can be returned by email to medico-legal@tst.nhs.uk 

Completed forms must contain enough information for the organisation to identify the applicant and locate the information. If the application does not state what information is required from a specific period of time, it is assumed that access is required to the whole medical records file. There is no requirement for the individual to give a reason why they wish to access their records.  The application should always contain the written consent of the patient (or their legal representatives) to the release of the information.

Direct access

The Data Protection Act does not provide applicants with the right to directly inspect their health records (for example while in hospital), but the Department of Health Policy on ‘Direct Access’ states that patients who actually wish to see their records should be allowed to do so if possible, subject to given exemptions and there are no compelling reasons to the contrary.

Fees

A fee may be charged to view health records or to be provided with a copy of them. To provide copies of patient health records the maximum costs are:

  • Health records held totally on computer: up to a maximum £10 charge.
  • Health records held in part on computer and in part manually: up to a maximum £50 charge.
  • Health records held totally manually: up to a maximum £50 charge.

All these maximum charges include postage and packaging costs.

To allow patients to view their health records (where no copy is required) the cost is £10 unless the records have been added to in the last 40 days.

If a person wishes to view their health records and then wants to be provided with copies this would still come under the one access request. The £10 fee for viewing would be included within the maximum fee for copies of health records.

Time limits

The Department of Health states that NHS organisations should endeavour to comply with subject access requests within 21 days, rather than the 40 days specified in the Data Protection Act 1998.

Consulting the health professional

Before information is released to a patient the Health Professionals with responsibility for the patient will authorise the release of records by signing a disclosure consent form.

Parental responsibility

As a general rule, a person with parental responsibility will have the right to apply for access to a child’s health record.  However, there may be exceptions to this. For further guidance please see Department of Health document 'Guidance for Access to Health Records Requests under the Data Protection Act 1998'.

Withholding Information

There are certain circumstances where information can be withheld from a subject access request.  Access can be denied or limited where the information might cause serious harm to the physical or mental health or condition of the patient, or any other person, or where giving access would disclose information relating to or provided by a third person who had not consented to disclosure. The organisation is not obliged to inform the patient that information has been withheld.

Supplying the Information

Information supplied should be provided in a permanent form unless this causes the organisation ‘disproportionate effort’ or the patient agrees to receive it in another form, (if for example the printed version is very lengthy or held in a remote archive). The data supplied must be intelligible and any abbreviations should be explained.

If an individual requests to view a record without obtaining a copy, an appointment will be made with a lay administrator.  In these circumstances, the lay administrator must not comment or advise on the content of the record and if the applicant raises enquiries, an appointment with a suitable health professional should be offered.

Inaccurate Information

If information recorded on the health record is inaccurate, patients have the right to have the information corrected.  However, if the patient disputes the accuracy but the Clinician maintains the information is correct, the information will remain unchanged but a note will be added to the records recording the nature of the dispute.

Subsequent subject access requests

Organisations do not have to comply with a subsequent request where they have already complied with an identical or similar request by the same individual, unless a reasonable interval has elapsed.  In deciding what a reasonable interval is, the nature of the data, why the data is used and the frequency with which the data is altered should be taken into consideration.

Access to the health records of deceased persons 

The Data Protection Act 1998 does not have any provision for access to the health records of the deceased.  Access, under these circumstances, is governed by the Access to Health Records Act 1990.  The personal representative (executor or administrator of the estate) of the deceased or any person who may have a claim arising out of the patient’s death may apply for access. Access should not be allowed if the patient indicated while alive that they did not wish to be given to a particular person (Please note there are two different access forms one for Data Protection Act 1998 and one for Access to Health Records 1990).

Complaints and Appeals

An individual has the right make a complaint under the Trust’s Complaints Procedure and should be advised to write with details to the Patient Advice and Liaison Service

Alternatively, an individual may prefer to take their complaint direct to the Information Commissioner (contact details below).

Further information

For further guidance please see the Department of Health Document ‘Guidance for Access to Health Records Requests under the Data Protection Act 1998’

Or from the Information Commissioner at the following address: Wycliffe House, Water Lane, Wilmslow, Cheshire, SK9 5AF

Telephone: 01625 545700

Website: www.informationcommissioner.gov.uk