Patients & Visitors

Patient Advice & Liaison Service (PALS)

Accessing your Medical Records

In this section:

Rights to access

As of the 24th October 2001, the Data Protection Act 1988 'Subject Access' superceded the Access to Health Records Act 1990, except in the case of a deceased person when the Access to Health Records Act 1990 will still apply. Everyone has the right to access personal data held about themselves in either computerized or manual form, whenever the record was made. This includes NHS medical records and private records made by doctors and other health professionals.

Who can see a medical record?
  • You.
  • Another person with your written permission.
  • A parent or guardian of a person under 16, if that person agrees.
  • A court appointed representative of someone who is not able to manage their own affairs.
  • Where the patient has died, the personal representatives and anyone with a claim arising out of death, may apply to see the records, or part of them. The person holding the records need not disclose anything that dates from before November 1991.
When can the record holder refuse to provide information?

The record holder has the right to make sure of your identity when you request information from your health records. If you are applying on someone else's behalf the record holder has the right to check that you have permission to do so. The record holder may refuse to disclose information from the health records:

  • when the Health Professional thinks access is likely to cause you or anyone else serious physical and mental harm.
  • when a record contains details that the patient has asked not to be revealed to a third party.
  • when disclosing the records would reveal information that relates to or identifies another person unless their consent has been given; except where it is reasonable to disclose the records without that person's consent.
  • where it is not possible to supply you with a copy of the required information (because for instance the records have been destroyed under the Guidelines laid down in the HSC 1999/053).
What to do if access is refused

If you feel that the refusal is unjustified then you may wish to consider making a formal complaint alternatively you could approach the PALS service to see if we can help. You can also seek advice from the Data Protection Commission.

back to top

Gaining Access to your Medical Record

How to gain access to a medical record

Apply in writing to the person who holds your record to request access to see them. Ask your Health Professional at time of consultation or while an inpatient to show and if necessary explain your current episode of care to you. You will need the patients written consent if you wish to inspect their record. If you wish to see the records of a patient who has died you must be either the legal personal representative or someone who has a legal claim arising out of the death.

If you want a copy of the records or a written explanation of any information in them you must make a written request to the person who holds your records. You will be asked to complete a form for this purpose. You may also have to produce some proof of your identity.

It may be possible to be shown the records immediately upon request. (Only if the consultant concerned is available to sit with the patient and only then those notes for the consultant's speciality.) if not, on application an appointment will be made for you to see them. If you have made a written request for copies, these will be sent to you on payment of the appropriate fee.

You may not want copies of all your records. The record holder will ask you to say which parts you want so as to save time and expense.

A copy of the form "RUH Request to access personal health records" is available below. The form must be printed and signed as appropriate and sent to the address shown.

Medical Record Access Form

Important information about your request for access to a medical record

How long will it take to get access?

Requests for access to your records should be dealt with promptly. It should take no longer than 40 days after the person holding your records has got your fully completed request, the fee for disclosure and, if necessary, proof of your identity and confirmation of the information you require.

The cost of obtaining access to your records

Under the Data Protection Act 1998 'Subject Access', access is free if you don't need a permanent copy (i.e. a photocopy) if the information in your records has been added to in the last 40 days. If you want a copy of the information in your records there may be a charge per copy up to a maximum of £50.

If your records have not been made or added to within the last 40 days prior to your application, you will be charged a fee of £10 plus a charge per copy and postage, if applicable. However if you make a request to view only there will be a fee of £10.

back to top

Understanding and Amending your Records

What to do if you don't understand something in your record

You have the right to have any part of the records that you do not understand explained by the relevant Health Professional on written request. You should not be charged for the explanation.

What to do if you feel something is wrong with your record

If you think that your records are inaccurate ask the record holder to correct them. They must make amendments or attach a statement from you. If you disagree with what is written about you, You have the right to apply to the court to have it erased.

How long does the NHS hold records for?

Hospital records are normally held for a minimum of 8 years and GP records for 10 years after the conclusion of treatment but there are lots of exceptions e.g. Children and young people, maternity records, mental health records, records of armed forces personnel and prisoners etc. The NHS has comprehensive guidance designed to advise record managers. The information is available on the Department of Health's website www.dh.gov.uk (external site opens in new window).

The document you are looking for is contained in the Publications, Policy and Guidance section The document is titled "Records management: NHS code of practice”. It was published in 2006 and its Gateway Reference is 6295 .   It has many sections with detailed guidance on the different types of records in Annex D1.

Retention and destruction of medical records policy.

back to top