1. A health record is any record, whether on computer or paper, which includes information about your physical or mental health or condition, and is made by, or for, a health professional involved in your care. So it includes your case notes, letters to and from other health professionals, x-rays, results of laboratory tests and scans.

A health professional includes:

GPs,  nurses, pharmacists, health visitors, dieticians, podiatrists, dentists, midwives, physiotherapists, orthoptists, clinical psychologists, hospital doctors, child psychotherapists, opticians, osteopaths, occupational therapists, chiropractors, speech therapists (employed by an NHS organisation), scientists employed as head of department by a health service organisation, art or music therapists (employed by an NHS organisation) .

2. The person who holds your records (the health professional or the person responsible for this at the hospital or health board) is known as the data controller.

How to apply

3. You can ask the health professional responsible for your care if you can look at the records for your current treatment. Otherwise, you must apply in writing, by post or by e-mail.

4. You should write to the person or organisation you believe holds the information about you (known as the data controller). If you want to see your hospital records, or if you are not registered with a GP, contact your NHS board or trust and ask them who you should write to. You may need to fill in an application form and give proof of your identity. They may ask you to provide enough information to help identify your records.

5. You do not need to give a reason for wanting to see your health records.

Who can apply?

6. You can apply to see your records as long as the data controller of health records is satisfied that you understand what this means. In Scotland, we assume that you understand what this means if you are over 12.

7. Someone else may apply for you if:

·         you have agreed to this;

·         you are under 16, and the other person has parental responsibility, or

·         you are an adult, and are not able to look after your own affairs and you have given that person a power of attorney, or if he or she has been appointed by the courts. Under the Adults with Incapacity (Scotland) Act 2000, someone can be given the right to help you under an intervention order, or a guardianship order.

8. Under the Access to Health Records Act 1990, you can apply to see the record of a person who has died. You can only see records made after 1 November 1991. You can only access that person’s records if you are their personal representative, executor or administrator, or if you have a claim for compensation as a result of that person’s death. If you are claiming compensation, you can only see information which is relevant to the claim.

9. The data controller of health records will only let someone apart from you see the information if he or she is satisfied that when you gave the information, you would have wanted it to be given to that person.

What can I see?

10. You are entitled to see your record and get a copy. The data controller will tell you where the information has come from, and who has access to it.

11. You may receive the information as a computer printout, in a letter, or on a form. It should be easy to understand, and any abbreviations, codes or jargon should be explained.

12. Some information on your record may be withheld from you. This includes information that:

·         could cause serious harm to your, or someone else's, physical or mental health;

·         could identify someone else, unless that person gives their permission; or

·         is legally sensitive, for example, a pre-adoption report, or a report to a children’s panel.

13. The data controller does not have to tell you if information has been withheld. If you suspect that information has been withheld without a good reason, you should contact the Information Commissioner's information line.

How long does it take?

14. Once the data controller has enough information to identify you and to find the records, and you have paid any fee, he or she must give you the information within 40 days.

What does it cost?

15. You can be charged a fee of up to £10 for each request if your record is held on computer. If your record is held on a paper file or a mixture of paper and computer files (and you want a copy of the information), you can be charged a fee of up to £50.

Corrections

16. If any information about you is incorrect or misleading, you are entitled to have it corrected or removed. If the data controller agrees with you, it must be corrected. If the data controller refuses your request to amend your record, you can ask the Information Commissioner to consider whether inaccurate information can be corrected or removed.

Compensation

17. If you suffer physical or financial damage as a result of inaccurate information, you have a right to compensation. If it is proved that you have suffered damage a court may also order compensation for any associated distress you have suffered.

18. You can also claim compensation if your information is lost, damaged, destroyed or given to someone else without the data controller's authority.

How can I complain?

19. If you are not happy about the way your application has been dealt with, you can:

·         write and complain to the data controller, using the NHS complaints procedure; and

·         complain to the Information Commissioner if you are not happy with how your complaint has been sorted out.

·         As a last resort, you can go to court.

1. The Access to Medical Reports Act 1988 gives you the right to see any medical report on you that a doctor has written for an insurance company or an employer.

2. This includes any doctor who is, or has been, responsible for your medical care - your GP, hospital doctor, consultant, or any other doctor who has treated or advised you. It does not include an independent doctor acting for the insurance company or employer.

How do I apply?

3. You don't have to apply. Before an insurer or employer contacts a doctor for a report on you, they must get your written permission and explain your rights under the Access to Medical Reports Act 1988.

4. The insurer or employer must ask you if you want to see the report before the doctor sends it. If you do, the doctor must be told this. You then have 21 days to arrange to see it. If you have not contacted the doctor by this time, the report can be sent off.

5. Even if you do not tell the insurer or employer beforehand, you can still see the report as long as you ask the doctor for it before it is sent off.

6. Once you have seen the report, the doctor must get your written permission before sending it.

7. The doctor must also keep a copy of any report for six months, and you have a right to see it during this period.

How much does it cost?

8. There is no charge for inspecting the report. You are entitled to a copy, but the doctor can charge a reasonable fee for providing it.

What information can't I see?

9. You can be refused access to any part of a report if it would:

·         in the doctor’s opinion, cause serious harm to your or someone else's physical or mental health;

·         show how the doctor planned to treat you in the future; or

·         reveal information about someone else or the identity of another person, unless that person has given their permission.

·         The doctor must tell you if, and why, any information has been withheld from you.

How can I correct mistakes?

10. You can ask the doctor to correct any part of the report that you believe is wrong or misleading. If the doctor refuses, you are entitled to prepare a written statement of your views, which must be attached to the report when it is sent.

11. You can refuse to allow the report to be sent. However, this may mean that you are refused insurance cover or a job offer.

How can I complain?

12. If you believe that someone has broken the Act (for example, the doctor, insurer or employer), you can go to court for an order to make them keep to it.