Whilst it is possible for you to informally access your medical records either by asking your doctor during a consultation or calling you GP surgery, the more usual way to obtain your medical records is to make a formal application to the healthcare provider from where you are receiving treatment.
Formal requests under the Data Protection Act 1998
The Data Protection Act 1998 grants you a legal right to apply to access information held by the healthcare provider that relates to you. This includes records held by your GP, optician, dentist, hospitals, physiotherapists or rehabilitation providers. You can gain access to your notes and records held by both the NHS and private care providers.
You do not have to provide a reason why you wish to access this information, as you have a legal right to access any information about your physical and mental health.
How to request your medical records
Requesting your records is simple. You must submit a written request to your GP or other treatment provider. Some practices may however have a specific form which they require you to complete before they will release your records.
Your request for your records is known as a Subject Access Request (SAR).
Which records to ask for
If you require a specific record it may be helpful to state the dates of the records that you require. However, when pursuing a medical negligence claim or personal injury claim, or if you wish to get an overview of the care that you have received, it may be beneficial to request ALL of the records held by that organisation.
What happens next?
Once your request is received, a healthcare professional will review your request and decide whether they can release the records requested to you.
Reasons for refusal
It is possible for your request to be refused on several limited grounds that include:
1) Releasing the information may cause serious harm to your physical or mental health
2) Releasing the information may cause serious harm to the physical or mental health of another person.
The Data Protection Act 1998 requires all records to be provided within 40 days of the request. Government guidance states that healthcare providers should however aim to respond within 21 days. In reality, accessing your records can take some time especially if numerous practitioners have been involved in your care.
The health care provider may impose a fee for accessing and copying your medical records. The maximum fee that a healthcare provider can charge is £50.00 per set of medical records. Therefore if you wish to access both notes and records from your GP and one hospital, the maximum fee payable would be £100.00.
If you are accessing your records with a view to pursuing a medical negligence claim or personal injury claim, if the claim is successful it may be possible to recover the fees paid. However, if you are not successful in bringing a claim, unfortunately this cost will not be recoverable.
Others accessing my records
Your health records are confidential and may contain personal and sensitive information. It is possible for another person or organisation to access your medical records where you authorise them to do so. It is common when considering a personal injury claim or medical negligence claim for your solicitor to ask you to sign a form of authority allowing them to access your medical records on your behalf.
Additionally it may be possible for someone with legal authority to make decisions on your behalf to access your records, for example someone with a power of attorney.
Accessing the records of someone who has died
The Access to Health Records Act 1990 stipulates that only specific people are allowed to access the records of someone who has died, which includes a personal representative or a person who may have a claim resulting from the person’s death. Your health records remain confidential even after you have died.
If you want to access a deceased person’s health records then you should make an application to the healthcare provider in writing in the same was as you would under the Data Protection Act 1998. You should let the provide know who you are and in what capacity you are seeking the access to the notes (e.g. as personal representative for the deceased).
You should be given access to the deceased persons medical records within 21 days if the records were updated within the last 40 days. However, if this is not the case the healthcare provider should provide the records within 40 days of the request.
You may be charged a fee for accessing the medical records of a deceased person. There will be no charge if the records have been updated in the previous 40 days. If the records have not been updated within the last 40 days then a fee of £10 will be payable to access each set of records. However, the healthcare provider can also charge for copying records. The healthcare provider must not charge you more than a reasonable fee for copying and posting the records. Please note however, that the maximum charge of £50.00 will not apply and the fees could be considerably more.
If you require any additional information about accessing your own, or a loved one’s medical records, or you are considering pursuing a personal injury claim or medical negligence claim then please contact one of our specialist team at headinjuryuk.com.