Your Rights to Access Your Own Medical Records

Understanding and accessing your medical records is a fundamental right that empowers you to make informed decisions about your healthcare. Every time a medical expert examines you, they update these records with information about any illnesses or conditions and the care and treatment you received.

In some cases, it may be necessary to access your own medical records for legal purposes, or because you have questions about the care you have received. In these instances, it is important to understand that you have a right to see these documents, and what to do in order to obtain them.

What are medical records?

Medical records, also known as health records, are detailed documents that contain the history of your healthcare. These records comprise a variety of information, including:

• Your medical history

• Diagnoses

• Medications

• Treatment plans

• Immunisation dates

• Allergies

• Radiology images

• Laboratory test results

Health professionals maintain these records to provide you with high-quality care, and to ensure continuity across different healthcare services.

Why would I need to access my medical records?

There are several reasons why you might want to access your medical records. Understanding your health history can help you make informed decisions about your treatment options and any lifestyle changes you want to make. Accessing these records is also essential if you're seeking a second opinion or transferring care from one healthcare provider to another. Moreover, reviewing your records can help ensure that the information is accurate and up-to-date, which is crucial for effective healthcare.

However, viewing your own medical records might also be necessary if you have experienced failures in care provision, and you are looking to file a complaint or make a medical negligence claim. In these instances, the information in your medical records could form a vital piece of evidence in helping you prove your case.

Am I able to access my own medical records?

Under UK law, you have the right to access your own medical records at any time. The Data Protection Act 2018, which is based on the EU’s General Data Protection Regulation, grants individuals the right to access their personal data, including health records. This is known as the right of access, or subject access request (SAR).

There are very few exceptions to this right, which ensures that the majority of individuals can review their healthcare information whenever necessary.

How do I access my medical records?

Accessing your medical records should be a straightforward process, but it requires you to follow specific steps to ensure your request is processed smoothly and efficiently:

• Identify the holder of your records: your medical records might be spread across different healthcare providers. Determine where your records are held - this could be at your GP’s surgery, at a hospital where you received treatment, or with any other healthcare professional you have consulted. If you have been treated by multiple services, you will need to contact each one separately.

• Submit a subject access request: the right to access your medical records is formalised through an SAR. You must make this request in writing, either by sending a letter or an email to the healthcare provider's data protection officer or the practice manager. While some organisations may offer a specific form to request access, it is not mandatory to use it; a simple written request is sufficient. Ensure your request is clear and concise, specifying the records you wish to access. If you are only interested in a particular part of your records, such as records relating to a specific treatment or time period, mention this in your request to help narrow down the search.

• Provide identification: to protect your privacy and ensure that medical records are not disclosed to unauthorised individuals, you may need to provide adequate proof of your identity when you submit your SAR.

• Specify the format: you can request to receive your records in various formats. You may ask for a physical copy, although most organisations now offer the option to access records digitally, which can be quicker and more convenient. Be specific about how you would like to receive your records.

• Await the response: once you've submitted your SAR, the healthcare provider has up to one month to respond. This period may be extended by up to two additional months for complex or numerous requests, but the provider should inform you within the first month if they need more time and provide an explanation.

Accessing your medical records should generally be free of charge, although a small fee might be charged for additional copies. If you encounter any difficulties or delays in accessing your medical records, you can seek advice from the Information Commissioner's Office, which enforces data protection laws in the UK. They can provide guidance and, if necessary, intervene on your behalf.

How to correct an error in your medical records

If you discover inaccuracies or omissions in your medical records, you have the right to make corrections. You should contact the healthcare provider holding the records and specify the exact errors and the corrections needed.

If the healthcare provider agrees that the information is incorrect, they should amend the records accordingly. If they do not agree, you are entitled to have a note of the correction request added to your records.

Can I nominate someone else to view my records for me?

You can nominate another person, such as a family member, friend or legal representative, to access your medical records on your behalf. This requires your written consent and adequate identification for both you and the nominated person.

It's important to make sure that you can trust the person you nominate, as they will have access to your sensitive personal health information.

The importance of accessing your medical records

Accessing and understanding your medical records can be  an essential aspect of managing your health and wellbeing. It enables you to participate actively in your healthcare decisions, ensures that the information held about you is accurate and complete, and gives you protection and accountability if something should go wrong.

By making sure you are educated on your rights to access your medical records, you can take a significant step towards taking control of your health journey.