Your GP keeps information about your health and the care and treatment you receive in your health record. This information is used by your doctor, nurse and other healthcare professionals to assess your health and, together with you, decide the appropriate care for you.
With your agreement, your GP may refer you to other services such as community care, Out of Hours or hospital. Your GP will share information about you only with the healthcare professionals involved in providing your care. Other services and health care providers will normally tell your GP surgery about the treatment they provide you and your GP or nurse will include this in your record. Further details can be found below in the section on Sharing & Consent
You have the right to see information your GP practice holds about you. They may charge for this. Please ask them about this
It may also be necessary to share your information with non-NHS services or health providers but only in accordance with the rights of the individual and statutory obligations or by law
Your Health Record
Your health record may be held in different formats, hand written (manual record) or held on computer (electronic). Collectively known as your “health record”, this will include;
- personal information, i.e. your address, date of birth and NHSnumber
- contacts you have had with healthcare services, i.e. clinic visits, doctors’ appointments, hospitaladmissions
- notes, reports and decisions about your treatment andcare
- results of tests, i.e. X-rays, blood tests or scans
And may also include:
- information from other health professionals, relatives orcarers
- information from social care services if they have been involved with yourcare
- information about close relatives where there is a family history of a particular condition
- Other information relevant to your health and wellbeing e.g. personal, family or work issues etc.
Your care providers will endeavour to ensure that your health record is kept up-to-date, accurate and secure and appropriately accessible to those providing your care and treatment.
How you can access your information
You have a right to see your health record.
An application to access your health record is known as a Subject Access Request.
Your GP Practice will be able to provide you with information about how to make a request, but generally:
- Your request must be made in writing to the records manager at your health centre, GP Practice or health professional in charge of yourcare.
- You will need to provide details to enable them to verify your identify and locate your healthrecords.
- It will assist those responsible for providing you with access if you are able to specify what it is within your record you want tosee.
- There may be a charge to have a printed copy of the information held about you (maximum cost£50).
- Facilities may be available to allow you to view parts of your health record via computer.
- It is important that you are aware there may be circumstances when information within your health record may be limited or withheld, for example, when it is in reference to a third party or where there is a concern that access would be harmful for your well-being or the well-being ofothers.
Visit the Information Commissioner’s website for further information about your rights and how to request your personal information.