Patient Access to Records Policy

Patients have certain statutory rights to have access to their own medical records under the Data Protection Act 1998, the Access to Medical Reports Act 1988 and the Access to Health Records Act 1990.

Patients can request access to their own written or computer records, but records may not be removed from the practice premises.

Assistance will be given by the Practice Manager or Practice Business Manager if access to the computer record is required, but in these circumstances a member of staff will be required to stay with the patient to ensure confidentiality of other patient’s records.

If a patient requests to see their written records, advise them that the practice requires 48 hours notice and that an appointment will be made. If a doctors input is required, the patient will need to book a twenty minute appointment with the appropriate doctorto view and discuss the patient’s records. The staff will pull the patient’s file and give to the relevant doctor so that the doctor can review the file (no changes are permitted to be made to the file without the patient’s consent). If the doctor is not required to be present when the patient views their files he/she is to brief the relevant member of staff who will inform the patient of his/her right of access to his/her file.

Legislation (Data Protection Act 1998)

  • Patients have right of access to any health records.
  • Request for this access should be made in writing within 40 days of the record being made.
  • The practice has 21 days to comply
  • If the request is more than 40 days after the entry the practice is permitted to charge up to £10, plus the costs of copying.
  • Third parties can have access on behalf of the patient if the patient giveswritten permission.
  • Corrections to records should be made only by a doctor and if agreed by the patient.
  • If agreement is not reached, a note to this effect shall be inserted into the record.
  • Disclosure of information entered into the patient record by another health care professional should only be made after consultation with that professional or an appropriate health professional in their absence.
  • Exemptions – where disclosure might cause serious harm (mental or physical)

- where there is identifiable information about a third party who has not given consent

- where access to a child’s record might not be in their best interest.

All members of staff have been given in-house training on the procedure of patient’s rights to access their medical records (Information Governance Training undertaken July 2009) and any changes in legislation are forwarded to all staff.

The named Caldicott Guardian for Audley Mills Surgery is:

Dr. Ralf Genthe.

The form requesting access to medical records is below.

SAD

October 2015

TO MEDICAL RECORDS

Data Protection Act 1998 Subject Access Request

Details of the Record to be accessed:

Patient Surname:
Forename(s)
Date of Birth

Details of the Person who wishes to access the records, if different to above:

Surname:
Forename(s)
Address:
Telephone Number:
Relationship to Patient:

Declaration: I declare that the information given by me is correct to the best of my knowledge and that I am entitled to apply for access to the health records referred to above under the terms of the Data Protection Act 1998.

Tick whichever of the following statements apply:

( )I am the patient.

( )I have been asked to act by the patient and attach the patient’s written authorisation.

( )I am acting in Loco Parentis and the patient is under age sixteen, and is incapable of understanding the request / has consented to me making this request. (Delete as applicable).

( )I am the deceased patient’s Personal Representative and attach confirmation of my appointment.

( )I have a claim arising from the patient’s death and wish to access information relevant to my claim on the grounds that… (Please supply your reasons below).

YOUR SIGNATURE: ……………………………………… DATE: ………………

NOTE: There is a fee of £10 for access to records. An additional fee of 35p per page is charged if records are to be photocopied. The fee must accompany this request. You will be supervised during access which is by appointment.

Cheques payable to: Dr. C.P.M. Lewis & Partners.

21 days prior notice is usually required.