Health Records

How To Access Your Health Records

This information sets out your legal right to see your health records and any medical reports made about you for an insurance company or an employer. However, it does not give a full explanation of the law. If it does not answer all your questions, you can get more detailed guidance from Eastern Health and Social Services Council about your rights as a patient in general.

GP practice staff will keep personal information about your health strictly confidential. The Data Protection Act 1998 gives you the right to see personal health information about yourself. This Act aims to protect your personal privacy. Personal information includes records held by GPs, hospitals and health professionals.

Health Records

A health record is any record, whether on computer or paper, which includes information about your physical or mental health or condition, and is made by, or for, a health professional involved in your care. So it includes your clinical notes, letters to and from other health professionals, x-rays, results of laboratory tests and MRI scans.

A health professional includes

  • GPs
  • Health visitors
  • Dieticians
  • Podiatrists
  • Clinical psychologists
  • Midwives
  • Hospital doctors
  • Physiotherapists
  • Dentists
  • Occupational therapists
  • Chiropractor
  • Nurses

The GPs and staff in the Health Centre are responsible for the care and security of this information.

How To Apply

You must apply in writing, by post or by e-mail (Reception.Z00157@gp.hscni.net) at least 30 working days in advance. You should write to the Practice Manager Mrs Catherine Rouse or any GP in the Health Centre. You may need to fill in an application form and give proof of your identity. You do not need to give a reason for wanting to see your health records.

You will find information on accessing your records and the appropriate form at the end of this NHS Guide (Annex C Page 14 & 15) - Access to Medical Records.  Please fill in this form and send to

Mrs Catherine Rouse , Practice Manager, University Health Centre at Queens, Elmwood Manse, 7 University Terrace, Belfast, BT7 1NP.

Who Can Apply?

Any person registered with the Health Centre for whom the Health Centre holds current records. Someone else may apply for you if:

  • you have agreed to this;
  • you are under 16, and the other person has parental responsibility, or;
  • you are an adult, and are not able to look after your own affairs and you have given that person a power of attorney, or if he or she has been appointed by the courts;

Under the Access to Health Records Act 1990, you can apply to see the record of a person who has died. You can only see records made after 1 November 1991. You can only access that person’s records if you are their personal representative, executor or administrator, or if you have a claim for compensation as a result of that person’s death.

What Can You See?

You are entitled to see your record with the supervision of a GP and get a copy. The GP will tell you where the information has come from, and who has access to it. You may receive the information as a computer printout, in a letter, or on a form. It should be easy to understand, and any abbreviations, codes or jargon should be explained.  Some information on your record may be withheld from you. This includes information that:

  • could cause serious harm to you, or someone else’s, physical or mental health;
  • could identify someone else, unless that person gives their permission; or;
  • is legally sensitive, for example, a pre-adoption report, or a report to a children’s panel;

The GP does not have to tell you if information has been withheld. If you suspect that information has been withheld without a good reason, you should contact the Eastern Health and Social Services Council.

How Long Does It Take?

Once the GP has enough information to identify you and to find the records, and you have paid any fee, they must give you the information within 40 days.

What Does It Cost?

Fees are outlined in the document Access_to_medical_records.pdf .

Corrections

If any information about you is incorrect or misleading, you are entitled to have it corrected or removed. If the GP agrees with you, it must be corrected. If the GP refuses your request to amend your record, you can ask the Information Commissioner to consider whether inaccurate information can be corrected or removed.



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