Access to Medical Records
Procedure For Access To Medical Records By Patients
Any clinical staff employed by Moss Grove Surgery will be expected to record clinical information on patient’s computer records.
The Government’s requirement for GP practices to move towards electronic recording of clinical information and electronic patient records, means that Moss Grove Surgery are gradually working towards this and hope their staff will take this into consideration when designing or implementing any new systems, clinics or amending current ways of working. The Practice became paperlight in 2005.
Any clinical staff working for or on behalf of Moss Grove Surgery and in their capacity as a clinician are able to access patient medical records within the remit of their involvement within the clinical care of the patient. Again it is hoped that any clinicians carrying out clinics or consultations within the practice for patients of the practice, will assist us by adding their findings to the patient computerised clinical record. This will obviously help us work towards the Government’s demands for full clinical sharing of information and patient date to enable the evolvement of the electronic patient record by 2005, as per the NHS plan, 2000.
Other than the Partners of the practice, no one will be allowed to take patient medical records away from the practice, the records being held by the practice on behalf of the Secretary of State. In extreme circumstances where they are required in connection with a complaint being dealt with outside of the practice, a request in writing will be made to the Practice Manager who will then discuss this with the Partners at the next Practice Meeting.
Access To Health Records Act 1990 / Data Protection Act 1998
Right of access is principally the patient himself. However, he can authorise another person on his behalf in writing. Parents will usually have a right to their child’s records but the child’s rights to confidentiality should be balanced against parental responsibility.
Dependants of the deceased are entitled to see the records, however, any person can have a note, signed by the patient, put in their records to state that they do not require anyone to be allowed sight of their records after death.
Doctor may not give any information detrimental to the patients health. Patients are allowed to request a copy of such details.
If you would like to access your records you will need to phone Sonia Clark, Surgery Manager to arrange a convenient time to come into the surgery. You can complete an Access to Medical Records Application Form (see disclaimer) prior to attending and bring it with you. We will require you to sign your completed form when you attend at the arranged time to see Sonia Clark.
You will need to bring the following documents with you:
- Proof of Identity e.g.
Passport/Driving Licence - Proof of your address e.g.
Household Utility Bill
Correspondence to you at this address
Fees
- Under the Data Proctection Act 1998, you can view your health records or request a copy. You can expect to pay the following:
- £10.00 for a copy of full computerised records.
- No more than £50.00 for a copy of records held manually.
- It costs nothing to view records if they are held in manual form and have been added to in the 40 days prior to your request, otherwise a £10.00 charge will be made for this service.
- A maximum fee of £10.00 can be charged if records have not been added to in the last forty days.
Period To Be Shown Records
- If the record has been added to within the last 40 days - period for giving access is 21 days from the day of application. If not the period is 40 days from the date of application.
- Patients can request sight or copy of extract from records, costs as above apply again.
Access Not To Be Given
- If it would disclose information which would cause serious physical harm or mental harm to the patient or any other individual.
- Where access to records might disclose information about a third party which may be identified by this information (unless third party has consented).
Notes
- Doctor does not have to inform the patient that he has withheld any or certain information.
- Patient’s can ask for corrections to be made to records.
- Doctors must be fully convinced that they have seen the patient concerned before giving any information.
- You will be requested to provide adequate identification in the form of driving licence, passport etc, before any information will be given.
- They must be fully satisfied that the patient is who they say they are.
- All requests to view medical Records must be made in writing to Practice Manager stating reason for information required.
- Speak to Sonia Clark, Practice Manager for further details.
