If you have questions about the medical treatment you have received then a starting point can be to obtain your medical records. You have every right to obtain a copy of your medical notes and the body supplying them is under a duty to provide them in full, without making any changes.
Obtaining your records can be empowering – looking through them can help you understand what happened and make the chain of events easier to follow. Without medical training, some charts or tests results might not make a great deal of sense, but how those caring for you interpreted the results should be recorded elsewhere in your notes.
Sometimes medical records reveal failures in communication, or show that not everyone caring for you read and considered your notes carefully before deciding on a course of treatment. If you identify these sorts of errors then you might want to make a complaint, or seek legal advice about a clinical negligence claim.
The process for obtaining your medical records is relatively simple, but can differ depending on whether you are applying for your own records, or those of a family member. To help you with the process we have put to together a step-by-step guide:-
How to Apply for Medical Records
Under the Data Protection Act 1998, you have a right to apply for access to your health information. You do not have to give a reason for requesting your records.
- Whose Records are you applying for?
If you are applying for you own records, you will need to provide a signed Form of Authority, which allows the GP or hospital concerned to release your records to you. (Please see the example template form which can be used).
If you are applying for medical records relating to someone else, you must have their authority to do so. In our experience, the most common reason for requesting the medical records of another person is when the patient lacks the capacity to make decisions (for example, as a result of a serious brain injury).
A parent or legal guardian may request their child’s medical records. In the case of older children, the hospital may also request that the child counter-sign the form. This is because older children can be judged to be competent to make decisions involving their care.
Requesting Records when the patient has died
Different rules apply when requesting the medical records of a deceased person. Only certain people have the right to apply for these under the Access to Health Records Act 1990. These are:
- The personal representative of the deceased person
- Any person who may have a claim resulting from the person’s death
You may be required to provide evidence of your claim and prove your identity
- Where should you apply to for medical records?
You should make your request in writing to the GP surgery. It is best to address your letter to the Practice Manager.
As you may know, hospitals in England and Wales are organised through NHS Trusts. This means that your records may not actually be at the hospital you were seen at, but may be dealt with by another hospital within that Trust.
It can sometimes be confusing to work out exactly who at the Trust you should be writing to in order to request medical records. Often, you can find this information on the Trust’s website, but this is not always the case. In our experience, it is best to telephone the hospital and ask to speak to the Access to Health Records department. They should be able to provide you with details of the contact or department at the Trust that you should write to, along with the precise address details. This means that your letter will go directly to the correct person, and this can save a lot of delay.
If you cannot find this information on the website and do not want to telephone then addressing your letter to “Access to Health Records Department” at the hospital is best.
- Time Limits
Under the Data Protection Act, your request for medical records should be met within 40 days of your request and payment of the fee. However, it can be a good idea to telephone the Trust/GP to enquire about the progress of your request after 21 days have elapsed, as there is government guidance which states that healthcare organisations should aim to respond to your request within 21 days.
The maximum fee which you can be charged for a copy of your medical records from each institution is £50. This includes postage and packaging. The only instance where the £50 charge can be exceeded is when you request the records of a deceased person. Where the health records of the deceased person have not been added to in the last 40 days, an administrative fee of £10 may be charged, plus an additional fee for copying and posting the records. There is no limit on this charge, but the Department of Health's guidance is that it should not result in the record holder making a profit, and that the fee should be reasonable and proportionate.
Payment is usually by cheque, but NHS Trusts are increasingly offering alternative payment options, such as by BACS, Internet Banking or credit/debit card.