SPICe regularly receives enquiries relating to constituents’ concerns over their health records held by their GPs.
We were recently asked what the legislative basis is for a patient’s right to ask for their NHS records to be changed or a note written by the patient to be added to the records where the patient has concerns about their content.
Patient rights
Patients have a right to access their medical records. However, different records are held in different parts of the NHS so it depends on which records it is that the constituent wants to see. To see GP records a constituent can simply write to the Practice Manager of the surgery. If it is hospital records that a constituent wishes to see then they will need to write to the Records Manager of the relevant hospital
NHS information
There is a leaflet called ‘How to see your Health Records’ on the NHS inform website. It includes the following Q&A:
“What if I think information in my health records is incorrect?
If you think information in your records is incorrect, first talk to a member of NHS staff providing your care. What happens next depends on whether or not NHS staff decide the information is incorrect.
If they decide the information is incorrect, they will put a line through it so that people can still read it but can see that it has been corrected. They will also attach a note to your records explaining why this has been done.
If they decide 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.”
Usually, information can’t 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.
Legislation
Section 6 of the Access to Medical Reports Act 1990 relates to the correction of inaccurate health records.
Section 5 of the Access to Medical Reports Act 1988 also provides patients with a right, subject to certain safeguards, to see any medical report written for an employer, prospective employer or insurer, by a medical practitioner who has responsibility for the their ongoing care.
Finally, the Data Protection Act 1998 gives people a broad protection in that it requires any information held about a person (not just health records) to be accurate. You can find more information about the Act’s data protection principles around keeping personal data accurate and up to date on the website of the Scottish Information Commissioner.
It should be noted that the Data Protection Act 1998 would not cover an opinion (as opposed to a fact) recorded in a patient’s records, unless the opinion is based on factual inaccuracies.
Emma Robinson, SPICe Enquiries Manager