Access to Patient Records

Practice Leads

  • Admin: Chris Rushton

Date Reviewed

6th July 2016

Date of Next Review

September 2017

All manual and computerised health records about living people are accessible under the Data Protection Act 1998.

Who can apply for access to medical records:

  1. Competent patients may apply for access to their own records, or may authorise a third party, such as their lawyer, to do so on their behalf.
  2. Parents may have access to their child's records if this is in the child's best interests and not contrary to a competent child's wishes.
  3. People appointed by a court to manage the affairs of mentally incapacitated adults may have access to information necessary to fulfil their function

When should medical information not be disclosed?

  • When it is likely to cause serious physical or mental harm to the patient or another person.
  • When it relates to a third party who has not given consent for disclosure (where that third party is not a health professional who has cared for the patient)

Doctors are not entitled to withhold information if patients exercise their right of access and none of the above exemptions apply. They can, however, delete any inappropriate comments and may find it helpful to discuss any potentially distressing entries with patients in advance of access.

What are the timescales for access?

  • Access will be given promptly and no later than 40 days from receipt of the fee and written request.
  • If access has been given, there is no obligation to give access again until a reasonable time interval has elapsed (what is reasonable is not strictly defined, but is arguable depending on the nature of the data, the purposes for which it is processed and the frequency with which it has been altered).
  • Doctors are not required under the Act to approach a third party for consent to disclosure, although may wish to in some circumstances. If consent is sought, doctors should, in the  meantime, release the remainder of the records
  • If the doctors are happy for the information to be viewed, it is not essential for a clinician to be present when the patient views the records. It may however be helpful for the person who assists patients with viewing their records to have a clinical background so that technical issues can be explained.

Other important points

  • Confidentiality of third parties must be maintained - any entries in notes must be prepared beforehand. This might be done by omitting names and identifying particulars from the records before disclosure, and care should be taken to ensure that the information is genuinely anonymous.
  • Patients are entitled to a copy of their records, for example a photocopy of paper records or print out of computerised records.
  • It is not necessary for patients to make a formal application for access to see their records - nothing in the law prevents doctors from informally showing patients their records or, bearing in mind duties of confidentiality, discussing relevant health issues with carers.
  • Fees will be charged as detailed in the practice fee’s protocol.