Access to Medical Records

1. Access to Medical Records David Barr & Emma Ray Kent Local Medical Committee

2. Health Records and Record Keeping • Includes computer & manual records, results, x-rays, photographs, etc. • Should be factual, legible and contemporaneous • Should include clinical findings, referrals, medication prescribed, etc. • Personal views about the patient’s behaviour or temperament should not be included • Should not be altered other than to remove inaccuracies • Should reflect any amendments/alterations

3. Who can access medical records? • Competent patients • Children and young people • Under 16s must demonstrate sufficient understanding (Fraser competent) • 12 and over are generally expected to have the capacity to give or withhold consent regarding the release of information in their health records • Parents and those with parental responsibility • Third parties such as solicitors and insurance companies with appropriate consent • Police in certain circumstances

4. Parents & those with Parental Responsibility • Parents can access the records of children unless it is contrary to the wishes of a competent child • Any person with parental responsibility can apply although who this includes is not always clear • Where more than one person has parental responsibility, both have access rights • When a child lives with their mother and their father applies for access, there is no obligation to inform the mother • Local Authorities can be granted parental responsibility • If there is any doubt legal advice should be sought

5. Police • Police can access records if they have a court order or warrant • They can request voluntary disclosure under section 29 of Data Protection Act • Practices should only disclose information with the patient’s consent or if there is an overriding public interest • These might include a serious threat to public health, national security, life & death or to prevent/detect a serious crime • Less serious crimes such as theft and damage to property would not usually warrant a breach of confidence

6. Solicitors & other third parties • Written consent is needed to release information to third parties, including Social Workers • If there is any doubt the patient understands to what they appear to have consented, Practices should check with the patient • The BMA strongly recommends that original notes are not sent to solicitors

7. Patients who lack capacity • Patients with mental disorders or learning disabilities should not automatically be regarded as lacking the capacity to give or withhold consent • Most people with mental impairment can make valid decisions about some matters that affect them • Nominated individuals can be appointed under both the Mental Capacity Act and The Court of Protection to make health and welfare decisions on their behalf • If there is no nominated individual requests should be granted if it is in the best interests of the patient

8. When should access be given? • GPs can show patients their records informally • Copies can only be supplied if a formal application has been made • This is called a Subject Access Request and should be responded to within 40 days • Patients should be advised of any fee payable

9. When should information not be disclosed? • If it is likely to cause serious physical or mental harm to the patient or others • This does not justify withholding comments in the records because patients may find them upsetting • If it relates to a third party who has not consented • If the patient has asked for the information to be kept confidential • Access is restricted by a Court Order • If disclosure is legally prohibited e.g. adoption records

10. What charges can be made? • The Data Protection Act sets out the fees you can charge which should be justifiable and reflect the actual costs incurred • For records held entirely on computer - £10 • For records held manually in part or full - £50 • To view records without copies - £10 (if added to in last 40 days, no charge applies) • If a patient views the record and then wants copies the maximum you can charge in total is either £10 or £50 as above • These are maximum fees and include staff time, postage, etc.

11. Deceased patients • Covered in Access to Health Records Act 1990 • Patient confidentiality extends beyond death • This needs to be balanced against the interests of justice and people close to the deceased patient • GPs should discuss with patients the possibility of disclosure after death where it is obvious there may be some sensitivity • These discussions should be recorded in the medical record • A patient’s representative or anyone who has a claim arising from the patient’s death has a right of access to information directly relevant to a claim • Any charges should be reasonable and justifiable

12. You can find BMA and DH advice on Access to Health Records on our website • www.kentlmc.org

13. Heales Occupational Health Service • OH Services & Health and Safety advice to all GP practices for all staff and GPs • Comprehensive service offering: • Pre-employment screening • Management referrals • Advice on rehabilitation • Health surveillance • Immunisation & vaccination • Workplace assessments • Occupational health advice and support • Health & Safety training • Needlestick and Sharps advice • Telephone 0870 7461903 or email kmgpohss@heales.com