Access to Your Health Records

What are health records?
These are records which:

• Consist of information relating to the physical or mental health condition of an individual, and
• Have been made by or on behalf of a health professional in connection with the care of that individual.

Your rights
All patients have the right to see their own health records under the Data Protection Act 1998. In addition, personal representatives of deceased patients and any person who  has a claim arising from the patient's death may have access to the records under the Access to Health Records Act 1990

Patients should note that access to their health records is exempted under the Freedom of Information Act 2000, and that the process and timescale for completing applications under the Data Protection Act 1998 is different. The Trust has 40 days in which to complete most applications.

There are two ways by which patients may access their own health records. Firstly, there is a formal request made after the patient has left hospital or consultation, whereby the patient can either receive a copy of the records or make an appointment to view the records at the hospital. (This formal request process is described in detail below). The request must be made in writing by completing and returning an application form to the Trust. Secondly, there is informal request process that can be made by the patient at the time of consulation or during an in-patient episode.

Under the Data Protection Act 1998, the following can have access to their records held by the Birmingham Women's Health Care Trust in accordance with the Trust's Records Management Policy:

• The patient.
• A person authorised in writing to make an application on the patient's behalf.
• A person with parental responsibility when the patient is a child. [See section  below for more information].
• A person appointed by the court to manage the patient's affairs because the patient is incapable (the Receiver as appointed by the Court of Protection).
• Where the patient has died, the patient's personal representative(s) and any persons  who may have a claim arising out of the patient's death.

The applicant also has a right to the following:

• An explanation of any terms in the records that they do not understand, e.g., technical language or terminology.
• The right to ask for corrections to be made to the record and to request a copy of the corrections. If the Trust considers that no correction is necessary, the applicant must be given an explanation for that decision and the Trust must lodge the request and the reason for refusal on the notes. Any correction made must not obliterate the entry - the notes are a contemporaneous record. The original entry (or entries) cannot be removed.

Children's records
Children over 16 and those under 16 who are capable of understanding the significance of their records' disclosure must  give their own consent to access. This judgement must be made by the healthcare professional in charge of the child's care. Otherwise, authority must be given by an individual who has parental responsibility under the Children's Act 1989.

Exceptions to access
The Trust has the right to deny access to a patient's health records if one of the following conditions apply:

• If in the Trust's opinion, based on the assessment of the healthcare professional in charge of the care, access would disclose information likely to cause serious harm to the physical or mental health or condition of the patient or to any other person.
• If giving access would disclose information which would identify information by or about a third party (this does not apply if the individual concerned has given their consent).

How to apply for access to your own health records
Download the 'Request for Access to Personal Information' (DPA1) form. Notes to assist in the completion of the form can be read here. Information on charges can be found here.

Applications should be made in writing using the application form. The completed form should be sent to:
Medical Records
Birmingham Women's NHS Foundation Trust
Mindelsohn Way
Edgbaston
Birmingham
B15 2TG

Alternatively, you can write to the above address, call the Medical Records Department on  44 (0)121 472 1377 ext 2650 or e-mail  jane.shakeshaft@bwhct.nhs.uk to request a form.

How to apply for access to health records relating to a deceased patient
Download the 'Request for access to personal information relating to a deceased patient' (AHR1) form. Notes to assist in the completion of the form can be read here. Information on charges can be found here.

Applications should be made in writing using the application form. The completed form should be sent to:
Medical Records
Birmingham Women's NHS Foundation Trust
Mindelsohn Way
Edgbaston
Birmingham
B15 2TG

Charges

1. Request for health records made under the Data Protection Act 1998
   - Health records: £27.50 to £50.00 dependent upon the number of sheets
   - Each x-ray: £10.00
   These charges include postage and packing.
   
2. Request for health records of a deceased person made under the Access to Health Records Act 1990
   - Requests will be charged a £27.50 - £50.00 dependent upon the number of sheets.
   - Each x-ray: £10.00
   - These charges include postage and packing.
   

Request for viewing health records at the Trust
An appointment can be made for patients to view their own health records on Trust premises. A member of staff will be present to assist with unfamiliar terminology. There is no charge for viewing records.

Trust leaflet 'Your information'
Click  to download the Trust leaflet  Your information: a guide to why the NHS collects information about you and how it is used.

More information
More detailed information can be found on the 'Frequently asked questions about accessing health records' page on the Department of Health's web site.

This page was last modified on Tue Jun 07 2011