Access to Health Records

This factsheet looks at your right to see your health records. It explains what to do if you think the information on your health records is wrong. On this page, when we say ‘record’ or ‘records’, we mean your health record.

Overview

  • When an NHS professional sees you, they will update your record with information about your illness and treatment.
  • Records are kept in different places. If you have seen mental health services, your record is kept there. Your GP will not have the information.
  • You can see your records. Your doctor can withhold information if it may harm your physical or mental health.
  • You should be able to see a copy of your record within 1 month.
  • Other people, such as an employer or insurer, can only see your records if you agree.
  • If you feel something on your records is wrong you cannot usually delete it. You can ask your doctor to add a note to show that you disagree.
  • You should be able to see your records online if you sign up for ‘Patient Online’.
  • You can have a ‘summary care record’ which gives the NHS important information about your health. This helps them to deal with emergencies. You don’t have to have one if you don’t want to.

From the 25th May 2018 the General Data Protection Regulations (GDPR) come into force. These regulations will replace the Data Protection Act 1998. We have provided updates throughout this page in line with GDPR changes.

For further information and the latest updates to GDPR you can see the NHS Digital Website here.

My records

What are my records?

When you see a health professional, they will update your health record with information about your condition and treatment. These records may be on a computer or handwritten.

Your record has information about your:

  • Diagnosis
  • Reports
  • Letters
  • Test results

Health records in mental health teams may have information about your care plan and time spent in hospital.

The NHS keeps detailed records locally so the person in charge of your treatment can see it. This means your GP surgery will hold records of your GP visits. Your mental health team will keep records of your appointments with them. 

Local NHS services must have a ‘data protection officer’. This is a professional who is responsible for processing all the data they record.

Your GP records and mental health team records are not kept together. Specialist services and your GP may share some important information about your care. This may include:

  • referral letters,
  • your diagnosis,
  • reports and results,
  • your medication,
  • your allergies,
  • any bad reactions to medications you have tried, and
  • your name, address, date of birth and NHS number.

Summary Care Records

When you are treated outside your GP surgery, healthcare professionals cannot access your records. They may be able to see a ‘summary care record’ instead. This holds important information about your health. Your GP will automatically start a summary care record.

The record will have information about:

For example, in an emergency doctors could look at the record to see if you are allergic to any medications. This can help them treat you properly.

You can put more information on your summary care record if you want. You could put information about long term health conditions or any difficulties you have. Your GP can also put more information in the record. They must usually have your agreement to do this. This is called giving your consent. If you can’t consent, your GP must justify why they think the extra information is needed.

Health professionals have to ask you before looking at your record. But if you are unconscious or can’t give consent, they can look at your record without your permission. If they do this they have to make a note on your record to explain why.

You can ask to see a list of who has looked at your summary care record.

If you don’t want a summary care record contact your surgery and tell them. Or you can fill in a form and hand it into your surgery. This is called ‘opting out’.

You can find a copy of the form here

How long are my records kept?

Records of your care are made every time you go to an NHS service. These services will keep your records for different lengths of time. The length of time depends on where the record is kept.

Normally records are kept for up to 8 years after you were last seen by the service or discharged. These are called ‘adult health records’. There are some exceptions explained below.

GP Records

Your GP surgery will create a record when you register there. This will be kept and updated for as long as you are still registered there.

Your GP record will be kept for 10 years after you die or if you move to another country.

Temporary patients

If you register as a temporary patient at a GP surgery, a record will be made of your appointment. This will be kept for a maximum of 2 years after you were treated there. In most cases this record will be sent to the GP you are registered with. Your normal GP surgery will include it in the record they keep.

Electronic patient records

Some NHS services and GP surgeries have electronic patient records. These records should also follow the rules explained above. At the end of the time period, the record should be destroyed. Or people using the computer system should not be able to access them.

Mental Health Records

These include details of any treatment you may have been given under the Mental Health Act 1983. This includes prisoners transferred to hospital for treatment under the Mental Health Act.

Your records will be kept for 20 years after you were last seen, or discharged from the act. Or if you die the records will be kept for 8 years.

Your mental health records can be kept for over 20 years if it is an ongoing case.

If your case was simple and you were treated in the community with a full recovery, then your record may be treated as a normal adult health record and only kept for 8 years.

Prison health records

Any records of treatment you received in prison are treated as normal adult health records. This means they are kept for a maximum of 8 years after you are discharged. Usually a note summarising the care you received is sent to your GP.

Records of long term illness or an illness that could reoccur

You might have a long term or reoccurring health condition that means you need a lot of care. In these cases the record could be kept for up to 30 years after you are discharged. If you die, then your records can only be kept for 8 years after.

Why

Why might I want to see my records?

There are different reasons why you might want to see your health records. For example you might want to:

  • check if there are any mistakes in your records,
  • find out background information about your healthcare, or
  • get evidence for a complaint about your healthcare.

What if the information on my record is wrong?

The information in your records should be correct and up to date. Some of the information will be a professional’s opinion. A health professional may have written an opinion about you that you think is wrong, however the NHS will usually not remove these opinions from your record. They need to keep this information because it shows why they made decisions about your care and treatment. It is unlikely that the NHS will delete or remove information from your records unless it is factually incorrect, like the wrong address or date of birth.

If your doctor agrees that the information is wrong, they may add a correction to your record. If your doctor doesn’t agree with you, you should be able to add a note showing this.

You should write to the record holder to tell them what you think is wrong and explain why. It’s a good idea to send this letter by recorded delivery. 

Other people

Can anyone else see my records?

Your health records are confidential. The NHS should not show your health records to anyone without your consent.

What if an employer or insurer wants to know about my medical history?

If your employer or insurer wants health information, they may ask your doctor for a medical report. They will not ask for your full medical records. Your doctor will need your consent to give them this information. This comes under the Access to Medical Reports Act 1988.

What if I lack capacity to access my medical records?

Mental capacity means being able to understand and make decisions. If you don’t have capacity to ask for your records then someone else may do this for you. You can read more about mental capacity here

Can I see my relative’s records when they die?

When someone dies, their health records are still confidential. Only certain people can see them.

The NHS was previously able to charge you for getting copies of these records, but this was changed by the Data Protection Act 2018. Now you cannot be charged for these records.

Access to your relatives’ health records comes under the ‘Access to Health Records Act 1990'.

Personal representatives and people with a claim

If you are a personal representative, or if you have a claim from the person’s death, you can apply to see the persons’ medical records.

Being someone’s personal representative means you deal with their affairs after they have died. This includes dealing with their property and bank accounts.

The law is unclear about what it means to have a claim from someone’s death, but this may include people who can take an inheritance. You can read more about being a representative here.

You need to contact the record holder with enough information to identify the records. You should include evidence to show you are the personal representative or that you have a claim. You may need to show a death certificate, the grant of representation or a copy of the will. You may also need to show proof of your identity.

If the person left a note in their records saying they did not want you to see them, then the NHS may hold them back.

Other people

You can apply to see someone’s health records if you do not fall into the above group. The NHS should think about:

  • If the person who died said if they wanted their records to be shared
  • If anyone will be distressed if the records are shared
  • The views of any surviving family
  • How long ago the person died
  • How much information you are asking for
  • Why you want the information
  • If you had a relationship with the person who died  

Coroners

When someone dies unexpectedly, the coroner can see their health records. They may get a copy to prepare for the inquest into the person’s death.

Complaints

How can I complain?

You may want to complain because:

  • the NHS has not dealt with your request within 40 days,
  • the NHS says you cannot see your records,
  • the NHS doesn’t give you all the information that you asked for, or
  • you disagree with the information in your records.

You can use the NHS complaints procedure to try and resolve these problems.

You can find more about ‘Complaints’ here.

The Information Commissioner’s Office can look into your complaint and ask the NHS to solve the problem. 

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