Which records can be seen?

• Written medical records.
• Records held on computer.
• Social services records.

The exceptions are described later in this leaflet.

Who holds and gives access to records?

• GPs.
• Hospitals.
• Dentists.
• Social Workers.
• Other healthcare professionals.

Who can see your medical records?

• You.
• Anyone who has your written permission.
• Your parent or guardian if you are under 16 and you agree or if the person holding your records feels it is in your best interests.
• A representative appointed by a court if you cannot manage your own affairs.
• After you have died, your personal representative.

How do you apply to see your records?

First ask the person holding your records if you can see what has been written. If your request is denied you have a legal right to ask again in writing.

The record holder may ask you to fill in a form or apply in writing. Remember Health and Social Services may hold a number of records about you and you may need to make several applications to different organisations. If you need help to apply contact your local Health and Social Services Council. When you have filled in the form, send it to the person holding your records.

How long do you have to wait to see the records?

Sometimes your records will not be available immediately. However it should take:

• No more than 21 days (if the record has been added to in the last 40 days); or
• No more than 40 days (if the record has not been added to in the last 40 days).

In certain circumstances, it may take an extra 14 days.

How much does it cost?

In some cases the record holder can charge you a fee for accessing your records and/or providing a photocopy of material you ask for. For more detailed information on when and what can be charged contact your Health and Social Services Council.

What happens if you do not understand the records?

The person holding the records must explain any part of the record which you cannot understand.

When can information be held back?

• If they are a deceased patient's records made before 30 May 1994 (except where they explain something written on or after that date).
• When, in the opinion of the person holding the records, seeing the information is likely to cause serious harm to your physical or mental health, or that of another person.
• When it is about, or has been given by, anyone except a doctor or another professional involved in your care, unless that other person gives their permission.
• When it contains information you expressly said must not be revealed.
• After your death, if the information is not directly relevant to a claim arising from your death.

How do you challenge mistakes in the records?

If you think any record is not accurate, you can ask the person holding the records to correct them. The person holding the records must either make the change or note your disagreement in the records. Whether or not the record is corrected, the person holding the records must give you a copy of the correction or the note free of charge.

How do you make a complaint?

If you think your rights to see your records have been unfairly denied, or that the law has not been followed, you have the right to complain. If you are not satisfied with the result of your complaint, you have the right to take the matter to court. For more information on making a complaint, contact your local Health and Social Services Council.

You have a right to be treated politely with respect for your privacy and dignity.