Obtaining copies of your medical notes

CANADA (further down the page)

UK

Some people will know their rights over these, others will not. I was told by the midwife in the hospital I was not entitled to my notes. The midwife that came to the house said she did not know if I was. The GP said they did not know and the health visitor sent me on a wild goose chase! A student doctor told me that I was not allowed them!

You are entitled to copies of your hospital, GP and health visitor notes under the Data Protection Act. You write to the appropriate organisation (the DPA advises that you send it by recorded delivery) and request all notes electronic and manual. The hospitals seem to send you a form to fill in. Therefore for hospitals I tend to advice that you just ring up for the form complete it and send it back as above.

For the hospital or GP it is obvious where the address is. I had no idea where the health visitor notes were held so I wrote to the council and they forwarded the letter to the appropriate place. I am guessing that if you have a good relationship with your GP they would be able to tell you, unfortunately I did not have that at the time.

If a certain about of time has passed since you were at the hospital they tend to charge you a search fee on top of the cost of copying. None of the above are allowed to charge more than £50 for your notes, if you get a decent person they will not charge you or charge you something reasonable. (My hospital notes cost me about £0.20 a sheet!).

I advise especially with hospitals that after a few days you ring to confirm that they have the form and that they will be sending the notes to you. Legally all of them have to return the copies within 40 days. I advise to ring and check as some people have not got their notes as broken photocopiers and so on have been used for excuses. Ringing and checking tends to avoid this.

Information Commissioner, Wycliffe House, Water Lane, Wilmslow, CHESHIRE, SK9 5AF.
Telephone 01625 545700 Fax 01625 524510
e-mail mail@dataprotection.gov.uk Website www.dataprotection.gov.uk

Whenever I have had to contact them they have always been very helpful and friendly.

I found this when clearing out my post ...

--- In nct_announce@egroups.com, Belinda Phipps
wrote: Newsletter editors might like to publish this information as many people do not seem to know this.

Medical Records for your baby's birth

Did you know that you are can have a copy of your case notes and your baby's case notes if you wish. This is a legal entitlement under the Access to Health Records Act 1990 and the Data Protection Act 1998.

To get a copy write to the Data Controller, Medical Records Department at the hospital where your baby was born/where you were treated. (NB If a home birth, write to the hospital where the midwives who cared for you are employed - likely to be the hospital nearest you). Ask the hospital to send you a full copy of your notes and all relevant attached documents (such as letters and laboratory results sheets) and the computerised records. If you or your baby have been treated at more than one hospital you will need to apply to each hospital. This because each hospital keeps its own separate set of notes.

If you want the notes your GP (family doctor) holds then write to the practice manager at the practice you attend.

For the Health Visitor notes apply to the Community Trust that employs her - or if in doubt to the Health Authority covering the county/area you live in.

You may also want notes held by social workers if they have been involved with you. Apply to the Social Services Department for these. They are also obliged to supply these to you.

Directory Enquiries an give you telephone numbers of NHS Trusts or if you call your local hospital they can give you the Health
Authority and Community Trust phone numbers and addresses.

Sometimes the data controller will send you a form to fill in so they can check you are who you say you are. Sometimes these forms ask why you are making the request. You do not have to fill this part in. There is no need for you to give your reasons if you do not wish to.

Sometimes the data controller will suggest you come to view the notes rather than have a copy. You are entitled to a copy and if you want
one write back and say you do not wish to view the notes at this stage you wish to have a copy sent to you.

You will be given a copy free if you apply within 40 days of your last appointment with that Trust. Otherwise you can be charged up to
£50 for administration/photocopying though most Trusts charge around £10-20. **??not sure if this is right, I know of the search fee.

If you cannot afford the fee you can view your notes free. The Trust will arrange a date for you to go and see the notes.

If you have any difficulties getting a copy of your notes contact Freedom for Information Campaign, Suite 102, 16 Baldwins Gardens, LONDON EC1N 7RJ

Your notes must be sent to you within 40 days of you asking for them. It is wise to keep a dated copy of your request letter so you can prove you did ask for your notes later if you need to.

Your medical notes make interesting reading and may give you a different perspective on birth of your baby. If you are thinking about
questioning or complaining about any part of your care it is helpful to get a copy of your notes so you can write your letter from a more informed position.

Sample Letter

your address
date
and if you wish telephone number

Dear Data Controller

Please supply me with a full copy of your notes and all relevant attached documents (such as letters and laboratory results sheets) and the computerised records relating to my treatment at your Trust/Practice .

My name is ......... address.......(if you know it add your NHS number - adding your date of birth can help them trace the record quickly).

I also require a copy of my son/daughters full medical notes and all relevant attached documents (such as letters and laboratory results
sheets) and the computerised records.

His/her name is ......... address.......(if you know it add their NHS number - adding their date of birth can help them trace the record
quickly).

Thank you,

Yours faithfully

CANADA

Obtaining copies of your Charts

You are legally entitled to get them on request. all you have to do is contact the hospital or doctor and they have to provide you with them. There is sometimes a fee to pay of $50 or so.