Health records are made and kept by different organisations – for example by GPs, Acute Trusts and Mental Health Trusts.
What is a “health record”?
A health record is information collected and recorded by a health professional about you and the care you receive. These records may be on a computer or hand written and will include information such as:
- Name, date of birth and address
- Contact health professionals have had with you; planned and unplanned appointments/ admissions to hospital
- Details about your care; treatment, advice and diagnosis of illness(es)
- Results of investigations, eg blood tests
- Letters to health or social care professionals involved in your care
- Relevant information from people who care for you and know you well
What are my rights to access my health record?
Individuals have the right to see their health records under the General Data Protection Regulation (GDPR) 2016 and Data Protection Act 2018, which are the laws that govern the use of personal information. Any organisation that collects personal information must comply with these laws.
Why might I want to see my health record?
There are different reasons why you might want access to your health record – for example, you might want to:
- Find out information about your healthcare
- Check if there are any mistakes in your record
- Find evidence to support a complaint about your healthcare
How do I access my health record?
Your GP or other health professional may allow you to view your records by making an appointment to do this. If you want a copy of your records you will have to apply for them.
The General Data Protection Regulation (GDPR) 2016 and Data Protection Act 2018 gives every living person the right to apply for access to their health records. This is called making a ‘Subject Access Request’. You will need to write to the organisation that holds your healthcare record to make this request. If you are unsure who to contact, your local Patient Advice and Liaison Service (PALS) will be able to offer some advice and support. You can search for your local PALS office here
You will need to be able to prove who you are by providing documents such as a passport or driving licence and a utility bill to confirm your current address.
Can anyone else see my health record?
Your health records are confidential but we may share your health information for direct care without your consent. The law allows us to do this because we are a public authority delivering healthcare services.
Do I have to pay to see my health record?
There is no charge made to access your health records.
How long will it take to receive a copy of my health record?
Once you have provided all the necessary information that is needed to identify your record you should receive your copy within 1 month.
Who can answer questions I might have about the way my personal information is used?
The NHS is a public authority and this means that we have to have a Data Protection Officer. The Data Protection Officer has expert knowledge and they make sure that personal information is used according to the law.
Real life experience
I always hated the thought that there were medical notes in existence that chronicled my descent into really serious mental ill health which was characterised by long and frequent hospital admissions. I used to think of all the ways I could possibly destroy them though bar theft or arson I knew this wasn’t really a possibility. When I first talked about getting my medical notes to read I was discouraged and put off by all the mental health staff involved in my care and from fellow service users. The general opinion seemed to be that no good could come from reading them, that they would be triggering and that they would make me distressed and even angry. That opinion made me wonder even more about what the hell was written in my notes.
In the end I decided to risk it. I was in recovery and felt in a good enough place to be able to read my notes without getting emotionally caught up in the content. It was a relatively easy process. From the trusts website I found the information I needed and contacted the medical records department. There was a timescale that they had to respond to me by and also details of the fees involved. I ended up applying to five different trusts for my records, some charged me, some waived the fees. Over the space of a few weeks confidential packages arrived on my door step. I had planned not to rush in to reading them to avoid being overwhelmed but I couldn’t help but just jump in. I didn’t read everything, there were key incidents that I focussed on, but I did plough quickly through a lot of material. It was without doubt quite a difficult experience, reading about my distress from an outsiders view really made realise how seriously unwell I had been.
It was strange to find really memorable distressing incidents recorded in only a couple of lines. What really struck me over all though was the sheer number of people involved in my care over the years - all the letters written, all the referrals for treatment etc. made, all the notes recorded, all the appointments made. Overall I was left with the sense that people really had cared and tried really hard to help me, even though at times it had felt as though I was completely alone. It was quite a revelation and actually had a positive effect on me. All that time that I had felt as though I was fighting the battle alone I actually wasn’t.