Get help Advice and information leaflets Seeing your medical records Contents Introduction How to get your GP records Using the NHS App to access records A guide to formally requesting medical records Requesting the records of someone who has died Seeing a child’s medical records Requesting the records of a vulnerable adult More information on medical records Complaints Useful links Introduction This leaflet explains how to get copies of your medical records in England and Wales. What is in my medical records? Your records include any information about your physical or mental health recorded by a healthcare professional. This includes records made by hospital staff, GPs, dentists, and opticians. It can also include health records kept by your employer. Here are examples of the type of information which could be included: Laboratory reports Recordings of telephone calls X-rays Letters Prescription charts Clinical notes. Why would I access my records? Some of the most common reasons for accessing medical records include: understanding a condition, coming to terms with a medical event or preparing to make a complaint. Can I view my medical records? Yes. You have a legal right to see your own records. You do not have to explain why you want to see them. Can my request be refused? Your request could be refused if: A health professional thinks seeing the records would be seriously harmful to your physical or mental health The records also relate to someone else. Can I nominate someone else to see my records? Yes. You can nominate someone else, for example a solicitor, to view your records. You must provide written consent. Do I have to pay? No. Under General Data Protection Regulation (GDPR) accessing your medical records is free. How to get your GP records You can view a summary of your GP records online. To do this register for online services. If you do not wish to use the online service, see section 4 for advice on formally requesting your medical records. What information does my GP record include? Your GP record includes information on medicines, vaccines, and test results. It will also include communications between your GP and other services. For example, referral letters and hospital discharge summaries. How do I register for online services? Find out what online service provider your GP uses. You can do this by asking them or visiting the surgery website Tell your GP surgery you want to sign up for online services either over the phone or in person. If you go to the surgery in person, take some form of photo identification and proof of address Fill in the short registration form you are given or sent Login using the registration details and instructions your GP surgery gives you. How else can I view my GP records? You can also view your GP records using the NHS App. See next section for more information. Using the NHS App to access records The free NHS App allows you to book appointments, order repeat prescriptions and view your GP medical records. Who can use the NHS App? The NHS App is for people aged 13 and over who are registered with a connected GP surgery. You can use some of the features without your GP surgery being connected. As of November 2019, 95% of surgeries are connected to the NHS App. How does it work? With the NHS App you can: Check your symptoms Book appointments Order repeat prescriptions View your GP medical record Register to be an organ donor Choose how you data is used. How do I access it? The NHS App is free to download from the App Store and Google Play. A guide to formally requesting medical records You can formally request your medical records in writing. You may wish to do this if: The information you need is not covered by your GP record You want hard copies of records You do not have online access You do not want to use online services. Here is a step-by-step guide to formally requesting your medical records: Step 1 Find out where your records are held. Your GP should be able to tell you this. Step 2 Write a letter or email making a formal request for copies of your records. Include information on exactly what you want to see. This template letter may be helpful. Step 3 Reply as soon as you can if you are asked for more information. Keep copies of any letters you send and receive. Step 4 When you go to view your records, take some form of identification such as a passport or driving licence. Do not send original documents in the post. What if I do not hear back? Most healthcare providers aim to respond to requests within three weeks. If you do not hear back within this time write again or call to request an update. If you have not heard anything after 40 days you can make a formal complaint. See section 9 for more information on how to do this. Additional support A sample request letter is included at the back of this leaflet. If you need extra help with any of the above stages you can call the Patients Association’s free helpline: 0800 345 7115. Requesting the records of someone who has died Can I ask to see the records of someone who has died? Yes, but only under certain circumstances. You can request the records if: You are the executor or administrator of someone’s estate You have a claim resulting from the death. How do I apply for access to the records? When someone dies their GP records are passed to Primary Care Support England. The person’s GP will be able to tell you how to access these. You can also find a list of local services at pcse.england.nhs.uk/services/gp-records/accessing-medical-records. This page also includes an application form. For hospital records, contact the records manager at the hospital the person attended. A sample request letter is included at the back of this leaflet. Do I have to pay? Fees may apply for accessing hospital records when someone has died. How long after someone has died can I still request their records? GP records are generally kept for 10 years after someone has died before they are destroyed. Hospital records are generally kept for eight years. Seeing a child’s medical records Can I see my child’s medical records? You can ask to see the records of a child under 16 if you have ‘parental responsibility’. What does parental responsibility mean? Parental responsibility means you are legally responsible for the wellbeing of the child. A more detailed explanation is available via gov.uk. Will my request automatically be granted? No. The best interests of the child will always be considered. If a healthcare provider is confident a child can understand their rights then they will send the information to them rather than the parent. Can I request the medical records of children over 16? Not without their written consent. I’m a foster carer, can I see the records of my foster child? You should check with the local authority or social worker to make sure you have the legal right first. Requesting the records of a vulnerable adult Vulnerable adults have the same right to confidentiality as anyone else. You may be able to see their records if a healthcare professional believes it is in the patient’s best interests. What does ‘vulnerable adult’ mean? A vulnerable adult is someone who may be unable to take care of themselves or protect themselves from significant harm or exploitation. Being a vulnerable adult does not automatically mean someone is incapable of making decisions for themselves. How can I request the records of a vulnerable adult? You should start by asking them. If they say yes, you will need their written consent before contacting their GP or healthcare provider. Will I automatically get to see the records? No. Healthcare professionals have to follow strict rules to protect the patient’s privacy and wellbeing. This might mean you will not be allowed to see the records. It could also mean you will only be allowed to see what the doctor thinks you need to know. What if the person is not capable of granting permission? If a person does not have mental capacity to manage their own affairs you have the right to request their records without their permission if either of the following applies: You have a lasting power of attorney with authority to manage their properties and affairs You have been appointed to make such decisions by the Court of Protection. More information on medical records Can I see original records? Yes. According to the Department of Health patients should be able to see their original records if they want to. If you want to see originals make sure you say this in your formal application. Will I understand the records? If you find the information in your records difficult to understand your healthcare provider should explain them. They should tell you what medical words and jargon mean. Can anybody else see my records? No. Your medical records are confidential. Nobody else is allowed to see them unless they: Are a relevant healthcare professional Have your written permission Have legal rights to deal with your affairs. What if I live abroad? If you have moved abroad permanently your GP records will have been sent to your NHS Local Area Team. Your last GP in the UK will be able to tell you how to contact them. GP records will be stored for 10 years. Hospital records will be stored for eight years. You cannot take originals abroad but you can request copies. What if I think the information in my records is wrong? You can contact your GP or health professional and they will help you update it. Complaints When can I complain? You can complain if: You disagree with a decision not to let you see medical records You are unhappy about the process You do not receive the records within 40 days You feel your information is being used incorrectly. Your first step is to complain to the provider. If you are still not satisfied, you can make a complaint to the Information Commissioner. Contact details for the Information Commissioner are at the bottom of this page. How do I complain to the Information Commissioner? To make a complaint through the Information Commissioner you should: Give your details Say what you think the healthcare provider has done wrong Send any relevant letters or emails Contact the commissioner as soon as possible. The Information Commissioner does not normally investigate complaints after more than a year. Complaints must be in relation to a living person. Information Commissioner contact details To make a complaint online visit ico.org.uk/make-a-complaint. England Wycliffe House Water Lane Wilmslow Cheshire SK9 5AF 0303 123 1113[email protected] Wales Second Floor Churchill House Churchill Way Cardiff CF10 2HH 0330 414 6421 [email protected] Useful links AVMA – avma.org.uk The charity for patient safety and justice. NHS UK – nhs.uk Information on GP online service Find your local PALS team Find out more about NHS Choices Download NHS App. NHS Scotland – www.nhsinform.scot How to see health records in Scotland. NHS Wales – www.nhsdirect.wales.nhs.uk How to get medical records in Wales. NIDirect – www.nidirect.gov.uk Information on accessing medical records in Northern Ireland. POWHER Advocacy Services – pohwer.net Information, advice and advocacy services across England. Gov.uk – gov.uk Information on parental responsibilities. Sources Source material for the information contained in this leaflet is available on request. Contact the Patients Association helpline The Patients Association offers a free national helpline providing specialist information and advice to help patients make sense of their health and social care. Patients can talk directly to trained advisers in strict confidence about any concerns, questions or general experiences they have regarding the NHS and social care systems. The helpline is open from 9.30 am to 5pm, Monday to Friday, and calls outside these times are returned as soon as possible during opening hours. If you would like to contact the helpline, please call free on 0800 345 7115, or visit the Patients Association helpline page on our website for more information.