Kent Local Medical Committee – March 2011

Access to Medical Records

David Barr & Emma Ray

Kent Local Medical Committee

Kent Local Medical Committee – March 2011

Health Records and Record Keeping

• Includes computer & manual records, results, x-rays, photographs, etc.

• Should be factual, legible and contemporaneous

• Should include clinical findings, referrals, medication prescribed, etc.

• Personal views about the patient’s behaviour or temperament should not be included

• Should not be altered other than to remove inaccuracies

• Should reflect any amendments/alterations

Kent Local Medical Committee – March 2011

Who can access medical records?•Competent patients

•Children and young peopleUnder 16s must demonstrate sufficient

understanding (Fraser competent)12 and over are generally expected to have the

capacity to give or withhold consent regarding the release of information in their health records

•Parents and those with parental responsibility

•Third parties such as solicitors and insurance companies with appropriate consent

•Police in certain circumstances

Kent Local Medical Committee – March 2011

Parents & those with Parental Responsibility

•Parents can access the records of children unless it is contrary to the wishes of a competent child

•Any person with parental responsibility can apply although who this includes is not always clear

•Where more than one person has parental responsibility, both have access rights

•When a child lives with their mother and theirfather applies for access, there is no obligation

to inform the mother

•Local Authorities can be granted parental responsibility

•If there is any doubt legal advice should be sought

Kent Local Medical Committee – March 2011

Police •Police can access records if they have a court order

or warrant

•They can request voluntary disclosure under section 29 of Data Protection Act

•Practices should only disclose information with the patient’s consent or if there is an overriding public interest

•These might include a serious threat to public health, national security, life & death or to prevent/detect a serious crime

•Less serious crimes such as theft and damage to property would not usually warrant a breach of confidence

Kent Local Medical Committee – March 2011

Solicitors & other third parties

•Written consent is neededto release information to third parties, including Social Workers

•If there is any doubt the patient understands to what they appear to have consented, Practices should check with the patient

•The BMA strongly recommends that original notes are not sent to solicitors

Kent Local Medical Committee – March 2011

Patients who lack capacity

•Patients with mental disorders or learning disabilities should not automatically be regarded as lacking the capacity to give or withhold consent

•Most people with mental impairment can make valid decisions about some matters that affect them

•Nominated individuals can be appointed under both the Mental Capacity Act and The Court of Protection to make health and welfare decisions on their behalf

•If there is no nominated individual requests should be granted if it is in the best interests of the patient

Kent Local Medical Committee – March 2011

When should access be given?

•GPs can show patients their records informally

•Copies can only be supplied if a formal application has been made

•This is called a Subject Access Request and should be responded to within 40 days

•Patients should be advised of any fee payable

Kent Local Medical Committee – March 2011

When should information not be disclosed?

•If it is likely to cause serious physical or mental harm to the patient or others

•This does not justify withholding comments in the records because patients may find them upsetting

•If it relates to a third party who has not consented

•If the patient has asked for the information to be kept confidential

•Access is restricted by a Court Order

•If disclosure is legally prohibited e.g. adoption records

Kent Local Medical Committee – March 2011

What charges can be made?•The Data Protection Act sets out the fees you can

charge which should be justifiable and reflect the actual costs incurred

•For records held entirely on computer - £10

•For records held manually in part or full - £50

•To view records without copies - £10 (if added to in last 40 days, no charge applies)

•If a patient views the record and then wants copies the maximum you can charge in total is either £10 or £50 as above

•These are maximum fees and include staff time, postage, etc.

Kent Local Medical Committee – March 2011

Deceased patients

•Covered in Access to Health Records Act 1990

•Patient confidentiality extends beyond death

•This needs to be balanced against the interests of justice and people close to the deceased patient

•GPs should discuss with patients the possibility of disclosure after death where it is obvious there may be some sensitivity

•These discussions should be recorded in the medical record

•A patient’s representative or anyone who has a claim arising from the patient’s death has a right of access

to information directly relevant to a claim

•Any charges should be reasonable and justifiable

Kent Local Medical Committee – March 2011

You can find BMA and DH advice on Access to Health Records on our website

www.kentlmc.org

Kent Local Medical Committee – March 2011

Heales Occupational Health Service

•OH Services & Health and Safety advice to all GP practices for all staff and GPs

•Comprehensive service offering:

•Pre-employment screening •Management referrals •Advice on rehabilitation•Health surveillance •Immunisation & vaccination •Workplace assessments •Occupational health advice and support •Health & Safety training •Needlestick and Sharps advice

Telephone 0870 7461903 or email kmgpohss@heales.com