My Doctor Refuses To Let Me See My Medical Records
1. Can I have a copy of my medical records?
Everyone has the right to have a copy of their medical records under the Data Protection Act 1998. You have a right to view medical records if they have been amended in the last 40 days. The records should be presented in a format, which a patient will understand.
There are some exceptions:
Access may be refused if healthcare professionals believe that information in the records is likely to cause serious harm to the patient or another person
Details about third parties might be removed from the records
If you are applying for access on behalf of someone else, you will need their consent or a power of attorney
2. How do I access my medical records?
Your GP holds your medical records. Notes from treatment received elsewhere, such as in a hospital, will be kept there. But your GP should also receive a summary report, and this will be added to your medical records. You can access records kept by other healthcare professionals such as dentists and opticians by following the same procedure as for your GP or hospital.
Request access informally
Your first step should probably be just to ask your GP or health authority if you can directly inspect them, although this isnt a right. You could also ring the surgery or hospital and arrange a time to visit.
Request access formally
You can also apply for access to your medical records formally in writing. If records are held at your doctors surgery, you should write to your doctor direct or to the practice manager. The Information Commission recommends that you send the letter by recorded delivery. If the records are held at a hospital, you should address the letter to your hospital Patients Services Manager or Medical Records officer. It is worth asking if there is a form you can fill in.
The advantage of applying in writing is that you are entitled by law to receive a response no later than 40 days after your application was received.
Proof of identity: You may be asked for proof of identity if you are applying to see medical records at places other than your GP surgery. You will need to ask for the relevant form and get a witness to sign to confirm your identity.
Charges for accessing medical records: There is usually a charge to see or get a copy of your records. This charge is 10 if you just require information that is held in a computerised format but if there are also manual records it could be up to 50. You can find out the exact amount by ringing your surgery, hospital or health authority. Send a cheque or postal order for the amount with your written request. If you dont send payment it may mean you dont see your records.
3. What if I am denied access?
If you are denied access you have a number of courses of action. You can approach the Information Commissioners Office if you think the organisation has breached the Data Protection Act by denying you access. Or you can complain through the NHS complaints procedure.
Complaining via the Information Commissioners Office
You need to approach the Information Commissioners Office and request an assessment form, which you need to complete. You can get a copy of the form by visiting their website or calling on their enquiry line: 01625 545 745
Send the completed form to the ICO with copies of any related document.
The health team of the Information Commissioners Office may be able investigate to see if the act has been breached. They can contact the organisation that has denied you access to your medical records for an explanation. They will hear their version of events. It may be that the organisation is relying on proper exemptions to the act.
If your complaint is upheld then access to your records will be granted. If not, you will have to complain by other means. You could do it via the NHS complaints procedure.
Complaining via the NHS complaints procedure
To use the NHS complaints procedure you must be a patient or former patient of the practitioner or institution involved and you must complain within six months of the incident.
There are two important stages to the NHS complaints procedure:
Local resolution and conciliation with your local primary care trust
An independent review that considers your complaint
Complaining to the Health Service Ombudsman
If you are denied an independent review, you can complain to the Health Service Ombudsman. The Health Service Ombudsman is independent of the government and the NHS. There is no charge for the service. The Ombudsman will not normally become involved unless you have already complained officially and are still unhappy.
How do I complain to the Ombudsman?
You should complain to the Ombudsman in writing. You can also use the complaints form available from the Ombudsmans office or on the website. Describe what happened in great detail and make sure you have copies of any relevant documents. The Ombudsman will only investigate if you have already suffered hardship or injustice.
You must complain within a year of becoming aware of the events which you are complaining about.
There is no appeal against the Ombudsmans decision.
There are four Ombudsmen, one each for England, Wales, Scotland and Northern Ireland. The addresses are:
See also : Access to Health Records Act 1990