Accessing your Medical Records

CAN I SEE MY MEDICAL RECORDS?

There is a legal obligation to keep your medical records, whether they are NHS or private medical records, and everyone has the right to see their records.

You do not always need to make a formal written application if you want to see your records and there is nothing to prevent healthcare professionals from informally showing you your own records. You can therefore make an informal request to see your records during a consultation or by phoning your healthcare provider.

Copies of your records are however only supplied if a formal application has been made. This application needs to be made in writing specifying your personal details and the treatment to which the request relates; it does not however need to explain why you want to see your records. Your records will usually be provided free of charge.

Access to your records can be refused if:

The records relate to, and identify, someone else;

When applying for another person’s records (for example a child’s), you would gain access to information they gave confidentially;

Healthcare professionals believe that information contained in the records would cause serious harm to your physical or mental health.

WHAT CAN I DO IF I THINK MY MEDICAL RECORDS ARE WRONG?

If you think that something in your medical records is wrong, the Patients Association recommends that you write to the GP or hospital saying what is wrong, and providing any evidence you have which supports your view. Medical records cannot usually be changed, but a note can be added explaining why they are incorrect. It is important that your records are accurate because the treatment you are given may depend on them. 

Medical negligence claims usually involve events which took place some time ago, so that clinicians cannot be expected to remember exactly what happened. For this reason both the you and the hospital or clinician will rely heavily on the medical records, which are supposed to be an ongoing summary of the patient’s condition or the treatment provided. The records may be unreliable for many reasons: perhaps because they were done in a rush and fail to include everything which is relevant, or because the clinician omitted to make a note and only realised that omission later, when their recollection was poor.

Very occasionally clinicians include things which they forgot to do at the time but claim to have done to avoid getting into trouble and sometimes records are destroyed or tampered with in order to show that errors did not happen.  Falsifying medical records is a crime if it is done with the intention to mislead, and clinicians who are found to have falsified records face being censured or struck off the register. It is not something which a clinician would do lightly.