Accessing Medical Records Guidance
Patient Records include:
- GP and hospital doctor records.
- Nursing records, and those made by other NHS staff.
- Records of your visits to the practice, clinic or hospital.
- Records of visits to you.
- Details of treatment, medication, tests and their results, diagnosis, referrals, etc.
Applying for your records:
- You have to apply to see your records and some GP Practices have a form specially designed for this that you are asked to complete. Ask at your GP for the form.
- For Stockport NHS Foundation Trust, this can relate to treatment at Stepping Hill Hospital, contact details to request the records are:
Patient & Customer Services
Medico Legal Support Team
Stockport NHS Foundation Trust
Stepping Hill Hospital
Tel: 0161 419 5425
- Alternatively the form can be downloaded from this page: https://www.stockport.nhs.uk/IG/ViewPage.aspx?p=3001
- In the case of a deceased patient, records can only be obtained by a Personal Representative. A Representative is usually an executor, next of kin or someone making a claim arising from the death, unless the deceased specifically requested in the records that they did not want that person to have access to their records.
- Trusts and GP Practices also have to explain to you anything in the records that is not easy to read, or which uses technical language that you do not understand.
- If you are applying to obtain someone else’s records, they must give you authority to do this in writing. This includes parents applying to see a child’s records, if the child is able to understand matters. Where a patient is unable to give permission because of incapacity or illness, you may need to seek legal advice and a court authorisation.
Under the Data Protection Act 1998 you have a right to see your records unless:
- Your doctor thinks that to do so would seriously harm you or another person.
Note: This refusal can apply to part of your records and there is no obligation to inform you of such a partial refusal. It is worth asking if any part of your records has not been made available.
If you think your records are inaccurate, you can ask for them to be corrected.
If the Trust or doctor disagrees with the changes you want to make, ask for a note recording your disagreement to be attached to the records. Any complaint about this can be made to the Data Protection Information Commissioner.