Patient Access to Records Policy

Patient Access to Records Policy

Patients have certain statutory rights to have access to their own medical records under the Data Protection Act 1998, the Access to Medical Reports Act 1988 and the Access to Health Records Act 1990.

Patients can request access to their own written or computer records, but records may not be removed from the practice premises.

Assistance will be given by the practice manager if access to the computer record is required, but in these circumstances a member of staff will be required to stay with the patient to ensure confidentiality of other patient’s records.

If a patient requests to see their written records, advise them that the practice requires 48 hours notice and that an appointment will be made with the doctor of the patient’s choice to view and discuss the patient’s records.

Pull the patient’s file and give to the relevant doctor so that the doctor can review the file (no changes are permitted to be made to the file without the patient’s consent). If the doctor does not require to be present when the patient views their files he/she is to brief the relevant member of staff who will inform the patient of his/her right of access to his/her file.

Prominent Points From The Legislation (Data Protection Act 1998)

• Patients have right of access to any health records.
• Request for this access should be made in writing within 40 days of the record being made. (Mintlaw Practice do not insist on written requests)
• The practice has 21 days to comply
• If the request is more than 40 days after the entry the practice is permitted to charge up to £10, plus the costs of copying.
• Third parties can have access on behalf of the patient if the patient gives written permission.

• Corrections to records should be made if agreed by the patient.
• If agreement is not reached, a note to this effect shall be inserted into the record.
• Disclosure of information entered into the patient record by another health care professional should only be made after consultation with that professional or an appropriate health professional in their absence.
• Exemptions – where disclosure might cause serious harm (mental or physical)
• - where there is identifiable information about a third party who has

not given consent

- where access to a child’s record might not be in their best interest.

All members of staff have been given in-house training on the procedure of patient’s rightsto access their medical records andany changes in legislation would be forwarded to all staff.