I’ll make a note of that...
We all trust our doctors to have our best intentions at heart, and to make sure we get the care and treatment we need. Doctors have always taken detailed notes of each patient’s health history, medical requirements, and their own recommendations as to how to proceed with treatment. But when was the last time you asked to see those notes for yourself? And do you have the right to see medical notes kept by professionals that concern your health and wellbeing?
The simple answer is yes, you do have the right to see them. Under data access laws, you can ask to see your medical notes at any time. Practices up and down the country have reported a marked increase in the number of requests since the introduction of GDPR in May 2018 by patients who want to know exactly what notes are being kept by their doctors.
Why would you want to look at your notes?
Fundamentally, what happens to your body or your mental health is your affair. You have every right to know what your medical team have recommended, what notes are being kept, and how those notes are affecting the way your health is managed by your GP, medical professionals or mental health experts. The UK Information Commissioner’s Office has issued a set of advisory notes to help ordinary people understand what rights to access they have, and whether or not your GP can refuse to let you see your medical records.
The ICO’s advice in brief
A GP cannot query your reason for requesting access to your personal medical records, and cannot refuse access to your information. They can, however, ask you or your representative to clarify the information you want to access, and only show you information that is relevant to your specific request. So for example, if you have been diagnosed with cancer, you can ask to see all the notes pertaining to the diagnosis and treatment of your condition.
Most records are kept online, so medical professionals can allow the patient digital access through an online portal to their records if so requested. That information has to be safeguarded so that it cannot be ‘hacked’ by using digital encryption, for example.
What if the notes are for someone else?
To stop anyone getting unauthorised access to confidential patient notes, there are certain safeguards in place, and medical professionals will be cautious about giving out any information unless it’s to the patient themselves. However, a patient can ask a close family member or legal representative to act on their behalf. The GP may ask for clear evidence that the patient has given their representative the right to access their records, and will refer back to the patient if they believe that more information than necessary is being requested.
If they are still concerned about the level of access the patient’s representative is asking for, GPs can choose to provide the patient with the information directly, rather than giving it to the representative. The patient can then decide for themselves just how much of that data they pass on to their representative.
Medical professionals do have the right to refuse a request if they believe it could cause serious physical or mental harm to the patient, or if the information you have requested relates to someone else and you do not have their expressed permission to access the data.
If you have asked for medical data and your GP has refused, you can then pursue the matter further either through the practice manager, or by making a complaint to the Information Commissioner.
Often, medical information is requested by a patient who may feel that the treatment they have received has contributed to a deterioration of their condition, or by a relative who may have questions as to how a member of their family is being treated. This often happens in medical negligence cases, which can be exceptionally complex in nature.
If you want to see your medical records and are being denied access by your medical care professionals, you may have to consider talking to a legal expert who specialises in data access or medical claims to help you resolve the situation.
If you have any questions about this topic, please feel free to contact Justin Emerson on 01245 228113 or firstname.lastname@example.org
This is not legal advice; it is intended to provide information of general interest about current legal issues.