Under the Data Protection Act 1998, you have a legal right to access your health records. If you want to see your health records, you can write to your Doctor, and then arrange a time to come in and read them. You don’t have to give a reason for wanting to see your records.
It’s a good idea to state the dates of the records that you want to see – for example, from 2009-2011 – and to send the letter by recorded delivery. You should also keep a copy of your letter for your records. You will usually receive a response to your request within 21 days, although the law states that your hospital, or the Practice, has up to 40 days to respond.
Hospital records as well as having a copy of your health records, the Practice will also have a summary of any hospital tests, or treatment, that you have had. Any hospitals where you have had treatment, or tests, will also hold records.
To see your hospital health records, you will have to contact your local Hospital.
Your request to see your records will be forwarded to the health records manager. The manager will decide whether your request will be approved. Your request will usually only be refused if your records manager, GP, or other health professional believes that information in the records is likely to cause you, or another person, serious harm.
Charges: If your records have been updated in the last 40 days – that is, you have seen your GP, or another health professional, in the last 40 days, you’re entitled to see your records free of charge. However, if your records are held on a computer, there may be an administration charge of up to £10.
For a copy of older paper records, and results such as X-rays, you may have to pay photocopying and administration charges. These charges will be a maximum of £50 (in total).
Optician and dental records:
Your optician and dentist also hold records about you. To access your optician or dental records, you may need to show proof of identity.
Power of attorney:
Your health records are confidential, and members of your family are not allowed to see them, unless you give them written permission, or they have power of attorney.
A lasting power of attorney is a legal document that allows you to appoint someone to make decisions for you, should you become incapable of making decisions yourself.
The person you appoint is known as your attorney. An attorney can make decisions about your finances, property, and welfare. It is very important that you trust the person you appoint so that they do not abuse their responsibility. A legal power of attorney must be registered with the Office of the Public Guardian before it can be used.
If you wish to see the health records of someone who has died, you will have to apply under the Access to Medical Records Act 1990. You can only apply if you:
are that person’s next of kin, are their legal executor (the person named in a will who is in charge of dealing with the property and finances of the deceased person), have the permission of the next of kin, or have obtained written permission from the deceased person before they died. To access the records of a deceased person, you must go through the same process as a living patient. This means either contacting the Practice or the hospital where the records are stored.
Emergency Care Summary
What does this information contain?
This is to let you know about changes in the way we in the NHS store your health records.
It tells you about something new – the Emergency Care Summary – which all patients in Scotland will soon have, and the benefits this will bring.
It explains how, in the future, all your health records will be stored and linked electronically, and why that will be good for your health care.
It’s happening now
All patients in Scotland have, or will soon have, something called an Emergency Care Summary.
What is an Emergency Care Summary?
This is a summary of basic information about your health which might be important if you need urgent medical care when your GP surgery is closed, or when you go to an accident and emergency department. It means that all NHS staff looking after you can get important information about your health, even if they cannot contact your GP surgery. Please go to Emergency Care Summary for further information.
Your Emergency Care Summary contains the following information.
- Your name
- Your date of birth
- The name of your GP surgery
- An identifying number called a CHI number (there is more about the CHI number later)
- Information about any medicines prescribed by your GP surgery
- Any bad reactions you’ve had to medicines that your GP knows about
Your Emergency Care Summary is copied from your GP’s computer system and stored electronically. NHS staff can then find it quickly if they need to see it.
Who can look at my Emergency Care Summary?
NHS staff can look at your Emergency Care Summary on computer if they need to treat you when your GP surgery is closed. They must ask you if you agree to this before they look at your information.
- If you agree, only the staff listed here will be able to look at your Emergency Care Summary
- Doctors, nurses and receptionists in out-of-hours medical centres
- Staff at NHS 24 who are involved in your care
- Staff in hospital accident and emergency departments
- In the future, ambulance staff may also be able to look at your Emergency Care Summary
- If you are unconscious, NHS staff may look at your Emergency Care Summary without your agreement. This is so they can give you the best possible care
How do I know that the information in my Emergency Care Summary is secure?
- The NHS stores your Emergency Care Summary electronically using the highest standards of security
- Only NHS staff directly involved in your medical care will be allowed to look at your Emergency Care Summary
- NHS staff can only look at your Emergency Care Summary if they have a password that allows them to
- A record will be kept of everyone who has looked at your Emergency Care Summary
- Your GP surgery will be able to check who has looked at your record if you want them to
What if I’m not sure that I want an Emergency Care Summary?
- If you don’t want an Emergency Care Summary to be made for you, tell your GP surgery
- Don’t forget that if you do have an Emergency Care Summary, you will be asked if staff can look at it every time they need to.
You don’t have to agree to this
Can I see my Emergency Care Summary?
- If you would like to see your Emergency Care Summary, ask your GP to print it out for you to have a look at
- If you think anything is wrong, ask for it to be changed
What does the future hold?
In the future, all patients in Scotland will have an electronic health record. The rest of this leaflet explains why this is important for providing the best possible care in the NHS.
What is an electronic health record?
- It is any information about your health and health care which is stored electronically
- We will use an identifying number called the Community Health Index number ( CHI for short) to link up the different parts of your health record held in different places within the NHS
How are my records stored at the moment?
- Most of your health information is recorded on paper files that are kept in different places. For example, you will have one set of records at your GP surgery, and another set at any hospital you have been to
- GPs and hospitals store some records electronically, but the different computers they use are not linked up. So when you go to a hospital, staff there cannot look at the health record held in your GP surgery
What are the benefits of electronic health records?
- NHS staff will be able to find medical information about you much more quickly
- Staff treating you will have a more complete picture of your health and your medical background. For example, we will be able to see quickly if you have any long-term medical conditions, or if you have recently had an operation
- This information will be available even when you are not at home – for example, if you are in another part of Scotland
- It will be easier for you to look at your own health records, for example, if you want to check that they are correct
How soon will I have an electronic health record?
- We are already storing some records electronically, but it will take some time before all your health records are
- It will also take quite a long time before we are able to link all your records, using the CHInumber
- Most test results are now stored on computer. This means your GP gets the results more quickly, without having to wait for a letter
- Letters about your care and treatment are often sent electronically between NHS staff and stored on computer. This may happen if, for example, your GP refers you to hospital or if you leave hospital
What if I do not wish my electronic health record to be accessed ?
- Please write to the the Practice Manager John Steel and we will update your practice records accordingly your electronic health records will no longer be shared
Do you need more information?
- A special helpline will be available until 30 September 2006 to give you more information about anything in this leaflet. Phone this helpline on 0800 85 85 31. The helpline is available from 11am to 7pm
- For information about your emergency care summary or electronic health records from 1 October 2006, phone the NHS Helpline on 0800 22 44 88
- If you want to find out more about your health records and how you can see what’s in them, ask for the leaflets ‘How to see your health records’ and ‘Confidentiality – it’s your right’. You can get these leaflets from:
- GP surgeries, dental surgeries, hospitals and any other places where you receive NHScare;
- the NHS Helpline on 0800 22 44 88;
- your local citizens advice bureau (find your nearest bureau on the internet at Citizens advice bureau or in your local phone book).
The content of this leaflet has been developed with Health Rights Information Scotland.
This information is produced by the Scottish Executive Health Department.
Please ask us if you would like this document on audio tape, in Braille, in large print or in Arabic, Hindi, Chinese, Bengali, Punjabi, Gaelic and Urdu.
Please e-mail ECSLeaflet@scotland.gsi.gov.uk