Accessing health records held in the Royal Berkshire NHS
Foundation Trust
Each patient using this Trust will have
an NHS health record containing information about their condition
and treatment.
This record is the property of the Royal
Berkshire NHS Foundation Trust and must never be taken off Trust
premises.
Occasionally, you may be given your record in a sealed envelope
to take to another clinical area; it is sealed to protect your or
any third parties' information. Under the Data Protection Act 1998
and Access to Health Records Act 1990, you have a right to see
information about you.
The information here explains:
- what an NHS health record is
- how you can apply for access to information held about you
- who can apply
- what to do if you are not happy.
What are my health records?
They are records that include information about your health and
any care or treatment you've received. This could be, for example,
test results, x-rays or letters to and from NHS staff.
Why look at my health records?
You might want to know more about treatment
that you've had or to check that your information is correct. It's
your choice whether to look at them and there can be a charge to do
this.
How and where are my health records kept?
- Your records can be written on paper, held on computer, or
both.
- Different parts of the NHS hold their own records. For example,
your GP's surgery and any hospital you have been to may hold
records about you. This web page refers to records held in the
Royal Berkshire NHS Foundation Trust.
How do I ask to see my health records?
You can see your records and, if you choose,
you can get a copy of all or part of your records. If you wish to
see them, you will need to make an appointment as a member of staff
will need to be with you whilst you read the records. If you have
any questions about the information contained within the record, a
subsequent appointment can be made with an appropriate clinician
who will be able to answer these questions for you.
You will need to apply in
writing using a form
that is also available from the Medical Records Department at the
Royal Berkshire Hospital, tel: 0118 322 7057. This form is also
available in
Polish,
Punjabi and
Urdu.
You do not need to give a reason for wanting
to see your health records.
Who can apply to see my health records?
Generally, you can apply if you're able to
understand what is involved in applying to see your records.
Someone else can apply to see your records
if:
- you have agreed to this, in writing
- you are a child who is able to understand what is involved and
the person applying has parental responsibility for you, and you
agree to it
- you are a child who doesn't understand what is involved, and
the person applying has parental responsibility for you
- you are an adult who cannot make decisions for yourself or
cannot tell others your decisions, and either you previously
granted that person Enduring Power of Attorney (EPA) before you
became unable to make decisions or a court has granted them a
guardianship order. EPAs in existence before 1 October 2007 will be
honoured but under the Mental Capacity Act (2005) new EPAs are no
longer awarded. (A person with capacity can now award a Lasting
Power of Attorney (LPA) to be used in the event of loss of
capacity. The LPA must be registered with the Office of the Public
Guardian when the person it concerns is no longer capable of making
decisions. The holder will be entitled to make decisions on your
behalf with regard to your care and can therefore access your
medical records using the proper process. The EPA attorney will be
treated as an "interested person" under the new law and therefore
will be consulted with regard to your care, and allowed access to
your notes in the proper circumstances.)
- They are a Receiver appointed by the Court of Protection before
1 October 2007. Under the Mental Capacity Act (2005), the Receiver
role ceased to exist from 1 October 2007. This is now a role
undertaken by a Deputy under the Court of Protection watched over
by the Office of the Public Guardian.
What will I see?
- If you look at your records in the hospital, you will need a
clinical member of staff (usually a consultant) with you while you
see them. What you see might be a paper file, a computer printout
or a photocopy. If you ask for a copy, it could be a computer
printout or a photocopy.
- The clinician should explain any jargon or words that you don't
understand.
- You will not be able to take the notes away to look at
them.
- Some information on your records may be kept from you. For
example, this includes information that:
- could cause serious harm to your, or someone else's physical or
mental health.
- could identify another person (except NHS staff who have treated
you), unless that person gives their permission.
- When someone else is allowed to see your records, that person
will not receive information that:
- you have told NHS staff that you don't want them to have
- you expected would be kept confidential.
How much does it cost?
If your records are paper or a mixture of
paper and computer records, and you just want to look at them,
there is no charge if they have been added to during the last 40
days. If they haven't been added to in this time, it costs up to
£10, unless you are in receipt of Income Support or a similar
benefit. If you want a copy of any part of them, under the Data
Protection Act 1998, the charge is up to £50.
After I've applied, how long will it take?
After you give NHS staff enough information to
identify you and your records, and pay any fee, you will get the
information within 40 working days.
What if I think information is incorrect?
If you think information in your records is
incorrect, first talk to a member of NHS staff providing your
care.
- If they decide that the information is incorrect, they will
score through it so that people can still read the information but
can see that is has been corrected. They will also attach a note to
your records explaining why the information has been scored
out.
- If they decide that the information is correct, they will not
change it. However, you can choose to have a note attached to your
records explaining why you think the information is incorrect.
In most cases, information cannot be removed
from your records unless a court orders it. NHS staff need your
full records to understand earlier decisions that were made about
your care and treatment.
Can I see the health records of someone who has died?
- Under the Access of Health Records Act 1990, the law allows you
to see records made after 1 November 1991. But generally, records
are only kept for three years after death.
- You can only see that person's records if you are a personal
representative appointed under a Will as executor or the personal
representative who is appointed as administrator of the estate when
the individual dies without a Will.
- will not be able to see parts of the records which:
- could cause serious harm to your/another's physical or mental
health;
- could identify another person (except NHS staff who have treated
the patient), unless that person gives their permission;
- the patient expected would be kept confidential.
- You will not be able to see the records of someone who made it
clear that they did not want other people to see their records
after their death.
What if I'm not happy?
If you are not happy about anything connected
with your application to see your health records, speak to someone
in the Medical Records Office. If the matter cannot be resolved, it
will then need to be addressed through the Trust's Complaints
Procedure.
If you believe that the Trust has failed to
provide information which you think you are entitled to, you can
write to:
The Chief Executive
Royal Berkshire NHS Foundation Trust
London Road, Reading RG1 5AN
You can also e-mail talktous@royalberkshire.nhs.uk
Under the provision of the Access to Health
Records Act 1990 and the Data Protection Act 1998, you also have
the right of action through the Information Commissioner and the
Court.
How to find out more
For more information about anything in this
leaflet, contact the Medical Records Department at the Royal
Berkshire Hospital, London Road, Reading RG1 5AN, tel: 0118 322
7057
This
information is also available to download in English,
Polish,
Punjabi
and Urdu.