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Access to Medical Records (GP Practice)

Medical Records - Primary Care Support England can only provide a copy of GP health records. Other parts of a patient’s health record may be held by hospitals, community or mental health trusts, as well as previous GP practices. We cannot provide access to these records, and you therefore may wish to apply separately to another health organisation. Click here.

Primary Care Support England does not store:

  • X-rays/transparencies – these will remain with the relevant NHS trust
    · digital records
    · hospital records – apply to the NHS trust
    · private clinic records – available from the clinic concerned.

 

Patient GP Registration Information and demographic information PCSE receive requests from a range of individuals and organisations to access demographic information including last known GP Practice. Click here.

On behalf of NHS England, the NHS GP Practice medical records for patients who have passed away should include information about:

  • medication
  • allergies
  • vaccinations
  • previous illnesses
  • test results
  • hospital discharge summaries
  • appointment letters
  • referral letters

Sometimes these records don’t always contain a full medical history.

PCSE will process the access application within 5 working days.

PCSE may contact you if additional information is required.

PCSE can only provide you with a copy of the information we hold in storage, as supplied by the Practice.

If you wish to speak to someone regarding this, please contact: pcse.accessrequests@nhs.net, or phone 0333 014 2884.

To appeal a decision on disclosure please email pcse.accessrequests@nhs.net

Please ensure to include a statement as to why you wish to appeal the decision.

If your appeal is accepted, it will be passed to the NHS England Redaction team to review the initial decision.

When an application is received by the Access to Health Records team, the steps listed in this guide, click here, detail the process that the application will follow. Applicants who require an update at any stage of the application should contact our Customer Support Centre on 0333 014 2884.

Deceased patient records no longer need to be printed and sent to PCSE.  However, PCSE will still continue to collect any legacy paper Lloyd George records.

If you work at a Practice and are unsure of what steps to take, please contact your ICB/Commissioner regarding the recent GP contract changes.

You remain responsible for the AHRA request but will need to contact PCSE to request the records, click here.

It is no longer a requirement for GP practices to print off the electronic/digital patient record for a deceased patient. GP Practices should still return the legacy paper Lloyd George medical record (if one exists) to PCSE and PCSE will store it on behalf of the Practice.  Should a Practice require an electronic copy of the Lloyd George record to respond to an Access to Health Record application you can request this from PCSE using the online form.

The Access to Health Records Act 1990 states that the medical records should be reviewed and if necessary redacted by the most appropriate healthcare professional before release. In most cases the appropriate healthcare professional is the most recent GP.  The healthcare professional is responsible for deciding whether access should be allowed, which records are appropriate for release and if any redaction is required.  There is further guidance around the redaction of records here

The Application should provide a signed authority for the application setting out whether they are the personal representative or, if not, state the basis under which their application is made e.g. they are the parent, sibling, etc of the deceased and have a claim as a dependent under the Fatal Accidents Act 1976.

If a solicitor is acting on a requester's behalf, it is the solicitor's responsibility to verify that the requester is the legitimate personal representative of the deceased or has a legitimate claim arising from the patient's death. The record holder can accept the solictor's statement that they have done the necessary checks, provided that they submit it to the record holder in writing by letter or email.

Documents requested from PCSE will be sent to the GP in PDF format. GPs can upload all documents, including PDF documents, into the record attachments section of the electronic patient record.

Practices may have access to redact patient records using internal software, e.g. in SystmOne called Subject Access Requests. Where electronic redaction software is being used and a patient record has been deducted when the user accesses the record, there will be a prompt to add data, then confirm YES and this allow them to override and add additional information/attachments.

Alternatively, Practices may choose to use third-party software such as IGPR or Adobe Acrobat Pro.

The access request has been sent to you as you are the last known GP Practice the patient was registered to. Please contact NHS England if you have any further queries regarding your role in an Access to Medical Records Request.