ABOUT HEALTH RECORDS
Health records play an important role in modern healthcare. They have two main functions, which are described as either primary or secondary.
Primary function of health records
The primary function of healthcare records is to record important clinical information, which may need to be accessed by the healthcare professionals involved in your care. Information contained in health records includes:
the treatments you have received,
whether you have any allergies,
whether you're currently taking medication,
whether you have previously had any adverse reactions to certain medications,
whether you have any chronic (long-lasting) health conditions, such as diabetes or asthma,
the results of any health tests you have had, such as blood pressure tests,
any lifestyle information that may be clinically relevant, such as whether you smoke, and
personal information, such as your age and address.
Secondary function of health records
Health records can be used to improve public health and the services provided by the NHS, such as treatments for cancer or diabetes. Health records can also be used:
to determine how well a particular hospital or specialist unit is performing,
to track the spread of, or risk factors for, a particular disease (epidemiology), and
in clinical research, to determine whether certain treatments are more effective than others.
When health records are used in this way, your personal details are not given to the people who are carrying out the research. Only the relevant clinical data is given, for example the number of people who were admitted to hospital every year due to a heart attack.
Types of health record
Health records take many forms and can be on paper or electronic. Different types of health record include:
consultation notes, which your GP takes during an appointment,
hospital admission records, including the reason you were admitted to hospital,
the treatment you will receive and any other relevant clinical and personal information,
hospital discharge records, which will include the results of treatment and whether any follow-up appointments or care are required,
image slides, such as those produced by a magnetic resonance imaging (MRI) or computerised tomography (CT) scanner.
There are strict laws and regulations to ensure that your health records are kept confidential and can only be accessed by health professionals directly involved in your care.
There are a number of different laws that relate to health records. The two most important laws are:
Data Protection Act (1998), and
Human Rights Act (1998).
Under the terms of the Data Protection Act (1998), organisations such as the NHS must ensure that any personal information it gathers in the course of its work is:
only used for the stated purpose of gathering the information (which in this case would be to ensure that you receive a good standard of healthcare), and kept secure.
It is a criminal offence to breach the Data Protection Act (1998) and doing so can result in imprisonment. The Human Rights Act (1998) also states that everyone has the right to have their private life respected. This includes the right to keep your health records confidential.
CARE.DATA Data to HSCIC to improve health services
How information about you helps
us to provide better care
The way information is shared between health care organisations has undergone change and more improvements are on the way.
Please download the various information leaflets which provide details about health care records and sharing. If you wish to opt-out of any aspect of data sharing please use the forms on this page and return to the surgery. Contact us if necessary for further information.
What is EDSM Enhanced Data Sharing Model?
On a patient by patient basis, eDSM uses a secure computer system that allows the sharing of full electronic records accross different NHS care services. It allows the patient to decide whether to share information out of an organisation and to control what information comes in to that organisation. The patient's decisions can be changed at any time.. This system is currently being rolled-out.
SUMMARY CARE RECORD Your emergency care summary
If you want to view your health records, you may not need to make a formal application. Nothing in the law prevents healthcare professionals from informally showing you your own records. You can make an informal request during a consultation, or by phoning your GP surgery or hospital to arrange a time to see your records.
Formal requests under the Data Protection Act
Under the Data Protection Act 1998, you have a legal right to apply for access to health information held about you. This includes your NHS or private health records held by a GP, optician or dentist, or by a hospital.
A health record contains information about your mental and physical health recorded by a healthcare professional as part of your care.
If you want to see your health records, you don't have to give a reason.
Applying for access to your health records
Depending on which health records you want to see, submit your request in writing or by email to:
your GP surgery
the hospital trust's health records manager or patient services manager
This is known as a Subject Access Request (SAR).
It's a good idea to state the dates of the records when you apply.
The health records manager, GP or other healthcare professional will decide whether your request can be approved. They can refuse your request if, for example, they believe that releasing the information may cause serious harm to your physical or mental health or that of another person.
Under the Data Protection Act, requests for access to records should be met within 40 days. However, government guidance for healthcare organisations says they should aim to respond within 21 days.
Someone else's medical records
FEES FOR ACCESSING YOUR MEDICAL RECORDS
You may be charged a fee to view your health records.
Fees to access health records
The fee to get a permanent copy of your health records will be different depending on how the information is stored. The maximum charges are:
£10 for records that are only held on computer
£50 for records that are only held manually, for example, paper records such as letters or hand-written clinical notes, or images such as X-ray film
£50 for records that are held partly on computer and partly manually (e.g. paper)
By law, you're entitled to receive a response no later than 40 days after your application is received and any relevant fee has been paid.
If the records you want are held manually, or partly manually and partly on a computer, and have been created or added to during the 40 days preceding the request; you can request a copy of the preceding 40 days of the health record free of charge.
Records that have been updated in the last 40 days
If the records have not been updated in the last 40 days and you don’t require a copy, the maximum charge is £10. This charge applies whether the records are stored:
partly on computer and partly in another form, for example, paper records such as letters or hand-written clinical notes, or images such as X-ray film
entirely in another form.
New Hall Surgery
We are registered under the Data Protection Act and staff are trained to protect your data
The UK’s independent authority set up to uphold information rights in the public interest, promoting openness by public bodies and data privacy for individuals.
YOUR GP RECORDS
Medical Records contain details of your lifelong medical history. They include details of your consultations with the doctor, illnesses, tests, prescriptions and other treatments that have been recorded by others involved in your treatment and care e.g. district nurses, social services etc. Accessing this information helps us provide you with appropriate health care.
Whilst some of this information is held electronically on computer, some may be held on paper. Data is retained to ensure you receive the best possible care both now and in the future.
Your GP is responsible for the accuracy and safekeeping of your medical records at the surgery. Please let us know if you change address and advise any change in contact telephone numbers.
We need to keep information about you so that you can deliver the best possible care and treatment. Information may need to be shared with other health professionals but your rights to privacy are protected - see further information about data sharing.
We may need to use some of this information, for example:
For the protection of public health – eg notifiable diseases
Planning – eg health screening data to Department of Health
Health research using non-identifiable data
Complaints investigations or legal claims - your consent required
Other statutory notifications
Please note that when your consent is sought in writing, unless you are happy for ALL of your records to be shared, you should only agree for sharing of the data relevant to the purpose of the consent.
KEEPING YOUR RECORDS UP TO DATE
PLEASE NOTIFY US IF:
You move out of our area
Change address within our area
Change home telephone
Change mobile telephone
YOUR RECORDS ONLINE
The NHS aims to ensure that you can access your health record on-line.
For more information click the download button. To register for access please contact the Practice Manager at the surgery