Access to Medical Records Policy

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This practice is committed to protecting patients’ confidentiality whilst upholding their rights to access their medical records. All access requests by patients and their representatives will be:

• Treated promptly (always within one calendar month, but sooner if possible).
• Verified to ensure that the person requesting access has the right to do so.
• Treated openly, with patients and their representatives being offered explanations of any information that they do not understand.

Procedure

Access to medical records is allowed under the Data Protection Act 2018 and the GDPR 2016. The following people are entitled to access:

• Patients.
• Patients’ representatives, provided they have the patient’s consent or a court order.
• Parents of a patient aged under 18 (16 in Scotland), although the patient’s consent will be requested if they have the capability to give it.

Access can take the form of:

• Viewing the record, and/or
• Receiving a permanent copy of the record or parts of the record
• Online via the NHS app

The practice manager is the practice’s data controller. All requests for access should be addressed to the data controller.

When a request is received, the data controller will:

• Verify the identity of the requestor and verify their right to access.
• Liaise with the patient’s healthcare team to plan the access.
• Contact the patient to arrange a suitable time to access their records.

The practice is obliged to withhold certain types of information as follows:

• Information within the record that relates to an identifiable third party, unless the third party gives consent or is a health professional.
• Information that would cause serious harm to the patient or another person.
• If a third party is seeking access with consent, information that the patient previously asked or expected not to be disclosed.
• Information subject to legal professional privilege between a patient and their legal advisor.
• Information restricted by a court, as it relates to current family and child court proceedings.
• Information about a person being born as the result of fertility treatment.
• Information prohibited by legislation concerning adoption reports and records, statements of a child’s special educational needs and parental order records and reports.

However, access will be given to the rest of the record.

If a patient wishes to view their medical record, the practice will ensure that a health professional is available to explain any terms that the patient does not understand. If a patient requests a copy of their medical record, the practice will provide an accompanying explanation of any terms that may not make sense to the patient.

If a patient disagrees with an opinion in the record or identifies an inaccuracy in the record, the record will be amended by noting the inaccuracy or disagreement alongside the original entry. The inaccuracy or opinion in question cannot be deleted as it may have a bearing on the medical history or future treatment.

Access to manual records of deceased patients which were made after 1 November 1991 is allowed under the Access to Health Records Act 1990. The records of deceased patients are generally held by PCSE and applications for access should be made to that organisation.

If the records are still held by the practice, access will be granted to people with a claim arising from the death of the patient in accordance with the Act.