Your Medical Records

Introduction

In the National Health Service we aim to provide you with the highest quality of health care. To do this we must keep records about you, your health and the care we have provided or plan to provide to you.

These records may include:

  • Basic details about you such as address, date of birth, next of kin
  • Contact we have had with you such as clinical visits
  • Notes and reports about your health
  • Details and records about your treatment and care
  • Results of x-rays, laboratory tests, etc.
  • Relevant information from people who care for you and know you well such as health professionals and relatives

It is good practice for people in the NHS who provide care to:

  • Discuss and agree with you what they are going to record about you
  • Give you a copy of letters they are writing about you, and
  • Show you what they have recorded about you, if you ask

We have a duty to:

  • Maintain full and accurate records of the care we provide to you
  • Keep records about you confidential and secure (see Confidentiality and the Data Protection Act)
  • Provide information in a format that is accessible to you (e.g. large type if you are partially sighted)

 

How your records are used

The people who care for you use your records to:

  • Provide a good basis for all health decisions made in consultation with you and other health care professionals
  • Deliver appropriate health care
  • Make sure your health care is safe and effective, and
  • Work effectively with others providing you with health care

Others may also need to use records about you to:

  • Check the quality of health care (such as clinical audits)
  • Protect the health of the general public
  • Keep track of NHS spending
  • Manage the health service
  • Help investigate any concerns or complaints you or your family have about your health care
  • Teach health workers, and
  • Help with research

Some information will be held centrally to be used for statistical purposes. In these instances we take strict measures to ensure that individual patients cannot be identified.

We use anonymous information, wherever possible, but on occasions we may use personal identifiable information for essential NHS purposes such as research and auditing.

However, this information will only be used with your consent, unless the law requires us to pass on the information.

 

Online Access To Your Records

Since 31 March 2015, all GP Practices are required to offer patients access to view the Summary information in their medical records.  This requirement is expected to be extended to cover the viewing of all clinically coded information by 31 March 2016.

We offer all our patients the option to view this information through the Patient Access  online service.  In addition, patients may be permitted to view their entire medical record online through this service, at their GPs discretion. 

For more information about online access to your medical records through the Patient Access service and how to apply, see Online Access To Your Records.

 

Your Rights

You have the right to confidentiality under the Data Protection Act 1998, the Human Rights Act 1998 and the common law duty of confidence. The Disability Discrimination and the Race Relations Acts may also apply. For more information about confidentiality, see Confidentiality and the Data Protection Act.

If you think anything in your medical record is inaccurate or incorrect, please let us know. Please also help us to keep your record up to date by informing us of any changes to your circumstances. See Keeping Your Details Up To Date for more information.

In additional to the right to view your summary record online (see Online Access To Your Records) you also have the right under the Data Protection Act 1998 and Access to Health Records Act to request to see your medical records.  Such requests should be made through the Practice Manager and may be subject to an administration charge.  In particular, there may be a charge to have a printed copy of the information held about you.

We are required to respond to any request within 40 working days.  You will need to give adequate information (for example full name, address, date of birth, NHS number etc.) and you will be required to provide identification before any information is released to you.

 

Notification

The Data Protection Act 1998 requires organisations to notify the Information Commissioner of the purposes for which they process personal information.