Accessing health records
A health record is any record of information (electronic or paper-based copy) about your physical or mental health that has been made by or on behalf of a health professional. Some examples are results of an MRI scan or x-rays and daily records of patient care.
Under the Data Protection Act (1998), you have the right to access any personal information an organisation holds about you. This is called subject access. Your carer, who could be a relative or friend, is usually allowed to ask for a copy for you with your written permission.
- Contact the health service, like a Marie Curie Hospice, surgery or hospital that you think holds personal information about you.
- A staff member will provide you with a subject access request form if needed. This will ask you to say what records you would like a copy of. If they don’t have a form, you can send your request in a letter or email.
- Fill in the form, or send your letter or email. If you have trouble, visit the Information Commissioner’s website for useful information (including letter templates) to help you write your request.
- Your request must be made in writing, either in a letter or email, for the organisation to consider it. Use recorded mail delivery or email to send your request to where your records are held. Keep a copy of the request and all correspondence about it.
- The service may ask for proof of identity like a passport from you or your representative, for example, your carer if they are asking for your health records on your behalf. If somebody is asking on behalf of somebody else then written authority will need to be shown.
An organisation may charge you a fee of up to £10 to access this information electronically. For paper-based or paper and electronic-based information, the fee can be up to £50 if you want to be provided with a copy of the records, depending on the amount of administrative work needed. However, these fees are sometimes waived.
To satisfy the request they need to give a hard copy of the information in paper or electronic form. They’re not allowed to request a fee unless they provide a copy of the information. Fees are used to cover general administration costs and are usually paid in advance.
If the information you’ve asked for is in electronic and paper form, and has been changed in the 40 days before the request, the organisation must let you see the documents for free.
- must reply within 40 days, starting from the day it gets the request plus the fee and information it needs to identify you and the records you’ve requested
- will contact you if it needs more information to find your records or to identify you
- will wait until it has all the information it needs and the correct fee before dealing with your request
- doesn’t need a reason from you for wanting to see your health records.
- should provide you with a copy of the information, but doesn’t have to if: it’s not possible, takes too much time or costs too much money, or if you agree to accessing it in another way, for example on a computer
- can hold back information sometimes if the information requested relates to another person, unless that person gives their permission, or it’s reasonable to provide the information without their permission
- may hold back medical information if its release would be likely to cause harm to your physical or mental health
If you’re caring for someone who is ill, you may want or need to access their health records for them. This could be to track their treatment or to get a better idea of their needs. Depending on what records you want to see, you’ll need to submit a subject access request by email or in writing to where the records are held with the person’s permission.
This could be:
- the person’s doctor
- the health records manager at the hospital where the person was treated
- any other place that holds personal information
You should send a copy of the person’s written permission with your request if possible. If the person is unconscious or unable to give consent, their health professionals can decide about the use of information.
You can also access a person’s health records if you have Power of Attorney for health and welfare, welfare Power of Attorney (in Scotland), or welfare guardianship.
If you’re considering accessing a person’s information where that person is unable to consent you should be clear that it’s in their best interests, and respects their wishes. You should also consider the feelings of other family members and carers.
Under the Access to Health Records Act (1990), you can view the health records of someone who has died if you’re:
- a personal representative
- an executor
- an administrator under Letters of Administration
- someone who has a legal or clinical negligence claim resulting from the death (this could be a relative or another person)
Family members or carers can’t access the dead person’s health records unless they are carrying out one of these roles.
This applies to information provided after November 1991 and access should be limited to records relevant to the claim being made. In Northern Ireland, this information is governed by the Access to Health Records (Northern Ireland) Order 1993 and allows for access to information provided after May 1993.
Access to information provided before these dates is at the discretion of the organisation holding the information. Records of adults who have died are usually held for 10 years.
If you’re struggling to understand the person’s illness, why they died or what type of care they received, it may be possible to speak to someone involved in their care. This could be by contacting where they were cared for, like a Marie Curie Hospice or getting in touch with the Patient Advice Liaison Service (England), Patient and Client Council (Northern Ireland), NHS Scotland or the Community Health Council (Wales).
Steps for accessing the health records of someone who has died
- Contact the health service – it will provide you with a request form.
- Complete and send back the form, including any fees that may apply.
You may be charged a fee of up to £10 to view information held on a computer or in paper form. Getting a copy of the records shouldn’t cost more than general administration costs like postage and copying.
- There is no charge if the records were added in the last 40 days before your application and you just want to look at them. Any copies you would like made and/or posted will have a small charge.
- If the records were added more than 40 days before you applied, there is a maximum £10 access fee.
- For supplying copies, a fee not exceeding the cost of making the copies and postal costs may be charged.
- Health professionals can also charge a professional fee to cover access costs. This amount can vary.
What can I expect of the hospice or service?
Someone will probably be with you when you see the records, either at the hospice or with you at home. Any medical or technical terms will be made clear in the records you receive.
If you think the information is incorrect, speak to a member of staff involved with the person’s care.
If you feel you haven’t been given all the information that you have a right to access, write back to the hospice or service to let it know what you think is missing.
The NHS in England uses an electronic record system called the Summary Care Record. If you’re registered with a GP practice in England, you’ll automatically have a Summary Care Record unless you’ve chosen not to have one.
What's included on a Summary Care Record?
A Summary Care Record contains important information about any medicines you’re taking, any allergies you suffer from and any bad reactions to medicines that you’ve had in the past. It includes your name, address, date of birth and your unique NHS number to help identify you correctly.
You can also choose to include additional information to your Summary Care Record. This might include:
- details about any long term health conditions, such as asthma, diabetes, heart problems or rare medical conditions
- relevant medical history, like treatments that you’ve had or care you’re getting
- your preferences about how you’d like to be cared for, and any religious beliefs or legal decisions that you would like healthcare staff to know about
- information about vaccinations you’ve had
If you’d like to add any of this information to your Summary Care Record, speak to your GP.
How Summary Care Records are used
The information in your Summary Care Record can help reduce the need to repeat information to different health professionals and make sure those caring for you have the most up to date information about your care. It’s designed to sit alongside any advance care plan that you may have. Healthcare staff in England will have access to the information in your record if they need it. This may be particularly helpful if you need unplanned care or when your GP practice is closed.
Healthcare staff will ask for your permission every time they need to look at your Summary Care Record. If they cannot ask you, for example, if you’re not able to communicate, they may look at your record without asking you, because they consider that this is in your best interest.
Viewing your record and opting out
If you’d like to see the information in your record, speak to your GP, who will be able to show you. If you don’t want a Summary Care Record, you can choose to opt out at any time by letting your GP practice know. If you change your mind simply ask your GP practice to create a new Summary Care Record for you.
This content is provided for general information purposes only. It's not medical, financial, legal or personal advice. We suggest that you consult with a qualified professional about your individual circumstances. How our information is created and how it's used.
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