Accessing Health Information by Rina Patel
Whenever you visit an NHS service in England a medical/health record is created.
A health record is any record which consists of information relating to the physical or mental health or condition of an individual made by a health professional in connection with the care of that individual. It can be recorded in a computerised form, in a manual form or a mixture of both. Information covers expression of opinion about individuals as well as fact. Health records may include notes made during consultations, correspondence between health professionals such as referral and discharge letters, results of tests and their interpretation, X-ray films, videotapes, audiotapes, photographs, and tissue samples taken for diagnostic purposes.
Health records must be clear, accurate, factual, legible and should be contemporaneous. They must include all relevant clinical findings, the decisions made, information given to patients, and drugs or treatment prescribed. Health records should not be altered or tampered with, other than to remove inaccurate or misleading information. Any such amendments must be made in a way that makes it clear that they have been altered.
Individuals have a right to access their own health record, and in limited circumstances, access to the records of other people.
When an individual requests access to a health record it must be done in writing but can be done verbally where a written request is not possible. The request should be handled within 21 days, although the Data Protection Act grants 40 days to comply. The Data Protection Act 1998 governs access to the health records of living people.
Hospital records are kept for a minimum of 8 years and GP records for a minimum of 10 years following treatment.
In relation to health records for deceased patients, they can only be accessed if it’s a personal representative or someone has a claim resulting from the death, however access may not be granted if the patient when alive requested confidentiality, this is governed under the Access to Health Records (1990).
There are some reasons why a health record is not disclosed, for example if it is likely to cause serious physical or mental harm to the patient or another person, or it relates to a third party who has not given consent for disclosure (where that third party is not a health professional who has cared for the patient).
While the responsibility for the decision, as to whether to disclose information, rests with the data controller, advice about serious harm must be taken by the data controller from the appropriate health professional. If the data controller is not the appropriate health professional, then the appropriate health professional needs to be consulted before the records are disclosed.
This is usually the health professional currently or most recently responsible for the clinical care of the patient in respect of the matters which are the subject of the request. If there is more than one, it should be the person most suitable to advise.
The Summary of Care Records is an electronic record of important patient information, created from GP medical records and other sources. Patients can ask to view or add information to their summary of care records by visiting their GP practice. It can be seen and used by authorised staff in other areas of the health and care system involved in the patient's direct care.
Due to the information being of a sensitive nature it needs to be treated with care. There are strict laws and regulations to ensure health records are kept confidential and can be accessed by health professionals directly involved in the care of that patient, information governance.