Access to Medical Records
The Access to Health Records Act 1990 gave individuals the right of access, subject to certain exceptions, to health information recorded about themselves, and, in certain circumstances, about others, within manual records. The Data Protection Act (DPA) 1998 came into force in March 2000 and repealed most of the 1990 Access to Health Records Act. All applications for access to records, whether paper based or electronic, of living persons are now made under the DPA 1998. For deceased persons, applications are made under sections of the 1990 Access to Health Records Act which has been retained. These sections provide the right of access to the health records of deceased individuals for their personal representative and others having a claim under the estate of the deceased.
The Right of Access
Under section seven of the DPA, patients have the right to apply for access to their health records. Provided that the fee has been paid and a written application is made by one of the individuals referred to below, the Practice is obliged to comply with a request for access subject to certain exceptions (see the procedure in Section 2). However, the Practice also has a duty to maintain the confidentiality of patient information and to satisfy itself that the applicant is entitled to have access before releasing information.
An application for access to health records may be made in any of the circumstances explained below.
Stanmore Medical Group has a policy of openness with regard to health records and health professionals are encouraged to allow patients to access their health records on an informal basis. This should be recorded in the health record itself. The Department of Health’s Code of Practice on Openness in the NHS as referred to in HSG (96) 18 Protection and Use of Patient Information will still apply to informal requests.
Such requests are usually made for a reason. The patient may have concerns about treatment that they have received, how they have been dealt with or may be worried that something that they have said has been misinterpreted. Staff are encouraged to try to understand and allay any underlying concerns that may have contributed to the request being made and offer an opportunity of early resolution.
Children of 16 Years or Over
If a mentally competent child is 16 years or over then they are entitled to request or refuse access to their records. If any other individual requests access to these the Practice should first check with the patient that he or she is happy for them to be released.
Children Under 16 Years
Individuals with parental responsibility for an under 16 year old will have a right to request access to those medical records. A person with parental responsibility is either:
- the birth mother; or
- the birth father on birth certificate (if married to the mother at the time of the child’s birth or subsequently) or;
- an individual given parental responsibility by a court.
(This is not an exhaustive list but contains the most common circumstances).
If ta health professional considers that a child patient is Gillick competent (ie has sufficient maturity and understanding to make decisions about disclosure of their records) then the child should be asked for his or her consent before disclosure is given to someone with parental responsibility.
If the child is not Gillick competent and there is more than one person with parental responsibility, each may independently exercise their right of access. Technically, if a child lives with, for example, its mother and the father applies for access to the child’s records, there is no “obligation” to inform the mother. In practical terms, however, this may not be possible and both parents should be made aware of access requests unless there is a good reason not to do so.
In all circumstances good practice dictates that a Gillick competent child should be encouraged to involve parents or other legal guardians in any treatment/disclosure decisions. Again medical records should not be disclosed unless the process set out in Section 2 is adhered to.
A patient can give written authorisation for a person (for example a solicitor or relative) to make an application on their behalf. The Practice may withhold access if it is of the view that the patient authorising the access has not understood the meaning of the authorisation. Records should not be disclosed unless the process set out in Section 2 is adhered to.
A person appointed by the court to manage the affairs of a patient who is incapable of managing his or her own affairs may make an application. Access may be denied where the GP is of the opinion that the patient underwent relevant examinations or investigations in the expectation that the information would not be disclosed to the applicant.
Access to a Deceased Patient’s Medical Records
Where the patient has died, the patient’s personal representative or any person who may have a claim arising out of the patient’s death may make an application. Access shall not be given (even to the personal representative) to any part of the record which, in the GP’s opinion, would disclose information which is not relevant to any claim which may arise out of the patient’s death. The effect of this is that those requesting a deceased person’s records should be asked to confirm the nature of the claim which they say they may have arising out of the person’s death. If the person requesting the records was not the deceased’s spouse or parent (where the deceased was unmarried) and if they were not a dependant of the deceased, it is unlikely that they will have a claim arising out of the death.
If you require any further information please contact the Practice Manager.