Revised December 2002

Guidance for doctors on access to health records under the Data Protection Act 1998, and on access to the health records of deceased patients under the Access to Health Records Act 1990, or the Access to Health Records (Northern Ireland) Order 1993

Summary:

The implementation of data protection legislation in early 2000 changed patients' statutory rights of access to their health records. The purpose of this guidance is to set out in some detail the legal requirements on doctors as holders of health records. This summary highlights the main points.

What records are covered?

All manual and computerised health records about living people are accessible under the Data Protection Act 1998.

Does it matter when the records were made?

No, access must be given equally to all records regardless of when they were made.

Does the Act cover all of the UK?

Yes.

Who can apply for access?

Competent patients may apply for access to their own records, or may authorise a third party, such as their lawyer, to do so on their behalf. Parents may have access to their child's records if this is in the child's best interests and not contrary to a competent child's wishes. People appointed by a court to manage the affairs of mentally incapacitated adults may have access to information necessary to fulfil their function.

Are there any exemptions?

Yes, the main exemptions are that information must not be disclosed if it is likely to cause serious physical or mental harm to the patient or another person or relates to a third party who has not given consent for disclosure (where that third party is not a health professional who has cared for the patient).

Must copies of the records be given if requested?

Yes, patients are entitled to a copy of their records, for example a photocopy of paper records or print out of computerised records.
Is it necessary for patients to make a formal application for access to see their records?

No, nothing in the law prevents doctors from informally showing patients their records or, bearing in mind duties of confidentiality, discussing relevant health issues with carers.

Can a fee be charged?

Yes, and the fee varies depending on the type of record and whether the patient wants copies of the records or just to see them.

To provide access and copies:

Records held totally on computer: £10

Records held in part on computer and in part manually: a reasonable fee of up to £50

Records held totally manually: a reasonable fee of up to £50

To allow patients to read their records (where no copy is required):

Records held totally on computer: £10

Records held in part on computer and in part manually: £10

Records held totally manually: £10 unless the records have been added to in the last 40 days when no charge can be made.