How do I obtain copies of my medical records?

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1 How do I obtain copies of my medical records? INJURY & NEGLIGENCE SPECIALISTS

3 WELCOME TO PANNONE PART OF SLATER AND GORDON When choosing a law firm, what do you look for? Quality service? Great reputation? Specialist solicitors at the top of their profession? Or simply friendly and approachable people? We offer all of these things. We focus on providing the highest standard of service with a personal touch that makes the difference. Our clients describe us as honest, professional and committed and in the words of the Legal 500 independent legal guide, we are excellent in every way, and never falter in support and availability. Our lawyers are easy to talk to and will keep you fully updated with no legal jargon. Whether you are entitled to legal aid, no win, no fee or legal expenses insurance, we ll find a way to fund your claim and fight for you. This booklet answers many of the frequently asked questions and explains the process for complaints about NHS Treatment (including GPs, dentists, hospitals, pharmacies etc.), Private Treatment and any other NHS service (including NHS treatment at a Private Hospital/clinic). Please call us on to set up a free consultation. Emma Holt National Manager of Specialist PI 03

Our clients describe us as honest, professional and committed and in the words of the Legal 500 independent legal guide, we are excellent in every way, and never falter in support and availability.

4 Injury & Negligence OBTAINING COPIES OF HEALTH RECORDS You are entitled to obtain copies of health records held by health professionals. WHO IS A HEALTH PROFESSIONAL? The following are all health professionals: GPs Hospital Doctors Midwives Nurses Opticians Health Visitors Dentists Pharmacists Physiotherapists Clinical Psychologists Child Psychotherapists Dieticians Podiatrists Orthoptists Osteopaths Chiropractors Occupational Therapists Speech Therapists Art or Music Therapists WHAT AM I ALLOWED TO SEE? 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. They can also include your case notes, letters to and from other health professionals, x-rays, results of laboratory tests and MRI scans.

Dieticians Podiatrists Orthoptists Osteopaths Chiropractors Occupational Therapists Speech Therapists Art or Music Therapists WHAT AM I ALLOWED TO SEE?

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6 Injury & Negligence ACCESS TO RECORDS FOR LIVING PATIENTS The Data Protection Act 1998 gives you the right to see your personal health records. How to apply To obtain copies of your medical records you should write to the person who holds them, i.e. your GP or the NHS Trust responsible for your care. When writing, you should make it clear that you want to receive copies of your records or you may simply be invited to look through them with a healthcare professional. You may be asked for proof of your identity or to complete an application form. (Note: You do not need to give a reason for wanting to see your health records) Who can apply You Someone else if you have given them written consent to see the records Someone with parental responsibility for you if you are under 16 Someone you have given a power of attorney or who the court has appointed as your representative if you are unable to look after your own affairs

When writing, you should make it clear that you want to receive copies of your records or you may simply be invited to look through them with a healthcare professional.

7 Can I be prevented from seeing my records? You are generally entitled to see a full copy of your health records but information can be withheld if: The appropriate health care professional believes that release of the information could cause serious physical or mental harm to you or someone else The information could identify someone else The information is legally sensitive You are not entitled to see copies of records made before 1 November 1991 except where a record helps explain a later entry. How long does it take? Once you have given enough information to allow the records to be identified and located and you have paid the fee, the healthcare provider should provide copies within 40 days. What does it cost? If you want a copy of information held on paper or computer files you can be charged a fee of up to 50. If you also want copies of x-rays or scans you may be charged a further fee as these are expensive to copy. 07

serious physical or mental harm to you or someone else The information could identify someone else The information is legally sensitive You are not entitled to see copies of records made before 1

8 Injury & Negligence ACCESS TO RECORDS FOR A DECEASED PATIENT The Access to Health Records Act 1990 provides the right for certain individuals to receive copies of a deceased patient s manual health records, since 1st November Any records before this date will not be disclosed to you, except where a record helps explain a later entry. How to apply? You should submit your request for the records to the record holder ensuring that it contains sufficient information (patient name, address, date of birth and hospital number, if known) to enable the correct records to be identified. You should also provide details of your relationship to the deceased. For GP records, apply to the GP practice if known. If not known, apply to the local clinical commissioning group (see For hospital records, apply to the records manager at the hospital attended Who can apply? The deceased s personal representative or executor or administrator can make the relevant application. Alternatively, any person who has a claim for compensation arising from the death of the deceased can make an application for the records i.e. if you are a dependant and have a claim for dependency.

You should submit your request for the records to the record holder ensuring that it contains sufficient information (patient name, address, date of birth and hospital number, if known) to enable the

9 Restrictions to access Health records may not be disclosed where: A third party (not a health professional) is identified without their consent It is likely to cause serious physical or mental harm The deceased provided the information confidentially to the health professional and requested non-disclosure Time limits for disclosure If you are applying to view records relating to the 40 day period before the date of application, you must be given the health records within 21 days. If the records relate to treatment provided more than 40 days immediately preceding the date of the application, then disclosure should be given within 40 days. Costs for obtaining records If the health records have not been updated in the 40 days preceding the application, a fee of 10 may be charged. Additional fees may be incurred for copying and postage and there is no limit on this charge. Some records (eg x-rays) may be expensive to copy. 09

period before the date of application, you must be given the health records within 21 days.

10 Injury & Negligence DEPARTMENT OF HEALTH RECOMMENDATIONS FOR STORAGE TIMES The period that different health records are stored for depends on the type of record and type of patient. The rules are laid out in the NHS Code of Practice ( Publicationsandstatistics/Publications) GP records minimum of 10 years Hospital records minimum of 8 years following the end of any treatment, or the patient s death if the patient died whilst receiving treatment WHAT HAPPENS NEXT? Once you have received copies of your records, you may wish to contact us again on or via clinicalnegligenceclaim@ pannone.co.uk Please remember legal proceedings must be issued within: 3 years from the date of injury and/or knowledge of an injury 3 years from the date of death, where limitation has not expired before the death In the case of children, before their 21st birthday There is no limitation of claims in relation to people who are unable to manage their own affairs and failure to protect your rights may result in them being lost altogether

uk/en/ Publicationsandstatistics/Publications) GP records minimum of 10 years Hospital records minimum of 8 years following the end of any treatment, or the patient s death if the patient died whilst

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11 CONTACT US Highest quality advice (ranked in top tier by leading independent legal guides Chambers and Legal 500) Free no obligation consultation Experienced specialist solicitors and principal lawyers who are Leaders in their field Range of funding options including no win, no fee and in certain cases Legal Aid National UK coverage and home visits Offices in Manchester and London For more information, or to discuss your claim, please contact Jane Whitaker jane.whitaker@pannone.co.uk Pannone part of Slater & Gordon have offices nationwide. To find your local office visit For further information, please go to:

12 For more information, please contact Jane Whitaker on or Slater & Gordon (UK) LLP is authorised and regulated by the Solicitors Regulation Authority.

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