Understanding your medical records
Many people are not aware that there is no centralised patient medical record. Records are held by the GP and by other groups (hospitals, care homes, clinics etc).
Non-GP records are only incorporated into the GP record if they are sent to the GP by the other source. This is sometimes done automatically, but often is not.
GP health records
Your GP health record includes information about the care you’ve had from your GP practice.
You can view your GP health record using the NHS App or by logging into your account on the NHS website. You can create an account online if you do not already have one. You don’t need to go into your practice to do this
To be able view your GP record online, you must be over 16 and registered with the practice.
Alternatively, you can ask for your GP record at your GP practice. They can give you a printed copy of your record or send you a digital version. They have 28 days to do this.
What’s in your GP health records?
- Medicines your GP has prescribed
- Allergies you have
- Vaccinations you’ve had
- Conditions you’ve been diagnosed with
- Notes from appointments at your GP practice
- Results of tests your GP practice has arranged
- Letters that hospitals or specialists have sent to your GP.
What’s not in your GP record
Information kept by other services (such as A&E, hospitals, hospices and care homes, dentists and opticians) that has not been sent to your GP – to get this information, you’ll need to contact these services directly.
More information can be found here and how to access your historic records can be found here.
View your GP health record – NHS
Privacy and security of your GP record
To give you the care you need, GPs keep information about your visits to practice staff who are involved in your treatment. These could be visits to a Doctor, Practice Nurse, Midwife, Health Visitor or Counsellor. Surgeries keep information about your health and lifestyle, and any illnesses, tests, prescriptions and other treatments that you have had because it may be needed the next time you are seen. This is called your medical records or medical notes. Your records are securely stored in a combination of paper (prior to 2010) and computer records.
Your GP is responsible for the accuracy and safe-keeping of your medical records.
More information about the security of your personal medical records can be found here.
Protecting patient data – NHS England Digital
Other sources of personal medical records
Other organisations hold your medical records in relation to your engagement with the. For example, if you attend A&E or a visit to see a consultant.
These records are not routinely sent to your GP. So, if you believe that your GP record has some gaps you should in the first instance speak to the records manager at the place where you attended. In some cases, GP administrators can access systems directly, but not always.
Requesting copies of medical records
A request for information from medical records has to be made with the organisation that holds your records – the data controller. For example, your GP practice, optician or dentist or care home.
For hospital records, contact the records manager or patient services manager at the relevant hospital trust. You can find a list of hospital trusts and their contact details here.
GP medical records for un-registered or deceased individuals
If you need make a request for the GP medical records of a deceased individual you will need to contact their last registered GP practice.
NHS England is only the data controller for GP medical records where an individual is currently not registered with a GP, or is deceased and the practice they were last registered with is now closed.
These records are held by Primary Care Support England (PCSE) on behalf of NHS England. To request access to GP medical records in these circumstances please visit the PCSE website.
Requesting amendments to your records
Health and care organisations make every effort to keep records accurate. However, occasionally information may need to be amended about you or the care given.
If you think that the health or care information in your records is factually inaccurate, you have a legal right to ask for your records to be amended. For instance, you can ask for your home address to be changed because you moved house. You may also ask for something you feel has been inaccurately recorded, such as a diagnosis, to be corrected. However, it may not be possible to agree to your request.
A request can be made either by speaking to staff or in writing. You may need to provide evidence of the correct details, for example proof of address or change of surname after marriage. The organisation will then consider the request. Where organisations agree to make a change, they should make it as soon as practically possible, but in any event within one month.
More information about the request process and your rights, can be found here.
Amending patient and service user records – NHS Transformation Directorate
Proxy access
Proxy access was developed to allow someone other than you to access and manage parts of their GP online services account. The proxy is given their own online access account (rather than using your login details). It is often used by the parents or recognised carers of young children, and recognised carers of adults.
Access given to authorised care staff must be agreed between the:
- Resident/patient and or their representative
- Care home
- Patient’s GP practice.
For children
If you care for a child aged under 16, and you have legal parental responsibility for them, you can usually get proxy access by asking the GP practice to set this up. You may need to fill in a form.
Before giving you access, the GP practice may need to check:
- ID for you and the child, for example passports
- Documents that help to prove you have parental responsibility, for example a birth certificate
- With anyone else that shares parental responsibility with you
- For safeguarding issues
- That the child consents to your access (agrees to it) or lacks capacity to consent, if they are aged 11 or over.
You do not have to live at the same address as the child to have access.
You can have proxy access for more than 1 child, and a child can have more than 1 proxy acting on their behalf.
More information on proxy access can be found here
Power of attorney and access to medical records
You should not assume that being a family member, or next of kin, gives you access to a patient’s medical record. If the person has capacity, then they must give specific permission for you to access their record and this will be noted
You may have Power of Attorney but this still does not give you access to the medical record , while the donor still has capacity.
Power of Attorney
If you’re aged 18 or older and have the mental ability to make financial, property and medical decisions for yourself, you can arrange for someone else to make these decisions for you in the future. This legal authority is called “lasting power of attorney”.
The person who is given power of attorney is known as the “attorney” and must be over 18 years old. You are known as the “donor”.
Lasting power of attorney (LPA)
Lasting power of attorney (LPA) includes health and welfare LPA and also property and financial affairs LPA.
Health and welfare LPA
A health and welfare LPA gives your attorney the power to make decisions about your daily routine (washing, dressing, eating), medical care, moving into a care home and life-sustaining medical treatment. It can only be used if you’re unable to make your own decisions.
More information about lasting power of attorney and its uses and requirements can be found here.