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Accessing Medical Records

Primary Care Support England (PCSE) stores medical records for:

  1. Individuals who are not currently registered with a GP practice in England
  2. Individuals who are deceased

If you are not registered with a GP practice in England and are looking to access your own medical record or if you are acting on behalf of someone else (who is not already registered with a GP practice in England), and wish to access their medical record, you can submit a ‘Subject Access Request’.

If you wish to access a medical record for someone who is deceased, you need to submit an Access to Health Record request.

Please note: Practices remain legally responsible for copies of records retained on local systems. Where a practice retains a copy (be it paper or electronic) of a deceased patient’s record, they are legally obliged to consider it under AHRA. They may choose to direct applicants to PCSE, but must also be prepared to respond directly if an applicant insists on accessing data retained by the practice.

Guidance from the GMC on the release of information for deceased individuals is available via the link below:

https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/confidentiality/managing-and-protecting-personal-information#paragraph-134

 



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Subject Access Request (SAR)

PCSE stores NHS GP medical records for people who are no longer registered with a GP, for example patients who move abroad or registered with a private GP.

If you are looking to make a Subject Access Request it must comply with the Data Protection Act 2018 (DPA) and can take up 28 days to process.

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.

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.

 

How to make a subject access request

  1. Download and complete the application form
  2. Send the completed application form along with your supporting documents to pcse.accessrequests@nhs.net

A list of supporting documents can be found within the application form.

We will:

  1. Process your application and order the medical record from our offsite storage facility
  2. The record will be photocopied
  3. An NHS England Health Professional will review the request and medical record in line with the Data Protection Act 2018 (DPA)
  4. If the Health Professional confirms that the records can be released a copy of the record will be sent to you and your request will be complete

Please see guide below on accessing NHS England encrypted emails.

A guide to accessing NHSE encrypted emails

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These records are sent to PCSE from people’s registered GP Practice and 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 your full medical history.

PCSE can only provide you with the information we hold about you.

A patient can request a copy of their own record and so can someone acting on behalf of a patient, this could be a legal representative, a parent or a court order.

All applicants will need to provide some documents to be able to access the records.

For requests made under the Data Protection Act 1990, PCSE will process the access application within 28 days.

In certain circumstances, this may not be possible (for example, where the record cannot be traced, or is held by a third party storage provider outside of the control of PCSE.)

PCSE will update the applicant on likely timescales.

 

FAQs

Your record may not always contain your full medical history.

 

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.

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.

If there are missing years, please contact the GP Practice you were registered with during the period you are missing the information.

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Access to Health Records Request

PCSE stores NHS GP medical records for individuals who have passed away. If you are looking to make an Access to Health Records request it must comply with the Access to Health Records Act 1990 (AHRA) and can take up to 40 days to process.

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.

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.

 

How to make an Access to Health Records Request

  1. Download and complete the application form
  2. Send the completed application form along with your supporting documents to pcse.accessrequests@nhs.net

A list of supporting documents can be found at the back of the application form.

We will:

  1. Process your application and order the medical record from our offsite storage facility
  2. The record will be photocopied
  3. An NHS England Health Professional will review the request and medical record in line with the Access to Health Records Act (1990)
  4. If the Health Professional confirms that the records can be released a copy of the record will be sent to you and your request will be complete

 

Please see guide below on accessing NHS England encrypted emails.

A guide to accessing NHSE encrypted emails

Open

The ethical obligation to respect a patient’s confidentiality extends beyond them passing away. The Access to Health Records Act 1990 (AHRA) provides a small amount of people with the right to access this information:

  • a personal representative (the executor or administrator of the deceased person's estate)
  • someone who has a claim resulting from the death (this could be a relative or another person)

Please note: Only information directly relevant to a claim will be disclosed.

All applicants will need to provide some documents to be able to access the records.

On behalf of NHS England, PCSE store NHS GP Practice medical records for patients who have passed away.

These records are sent to PCSE from GP Practices and 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 can only provide you with the information we hold about you.

If the request for a medical record is under the Access to Health Records Act 1990, PCSE will process the access application within 40 days.

In certain circumstances, this may not be possible (for example, where the record cannot be traced, or is held by a third party storage provider outside of the control of PCSE.)

PCSE will update the applicant on likely timescales.

 

 

FAQs

A record may not always contain the patient's full medical history.

PCSE can only provide you with the information we hold.

If there are missing years, please contact the GP Practice where the patient was registered during the period you are missing the information.

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.

I am the personal representative of the deceased and I haven’t received the records I expected following my request.

The personal representative/executor of the estate of a deceased patient has the right to apply for access to that patient's records.

However, the NHS Health Professional, when making their decision on disclosure, may limit the disclosure of the records if sufficient information regarding the reason the record are required has not been provided.

 

Exemptions to disclosures of information relating to deceased patients

If the deceased person had indicated that they did not wish information to be disclosed, or the record contains information that the deceased person expected to remain confidential, then it should remain so unless there is an overriding public interest in disclosing.

In addition, the record holder has the right to deny or restrict access to the record if it is felt that:

  • disclosure would cause serious harm to the physical or mental health of any other person;
  • or would identify a third person, who has not consented to the release of that information.

This may happen if the NHSE Health Professional, in the process of disclosing the records, finds that the records are either incomplete or contain illegible notes.

This is because PCSE do not hold the notes in question and they are still retained with the last practice. You would need to direct the request to the last registered practice for the missing/illegible notes.

As the GDPR/DPA only applies to living individuals, the concept of a data controller does not apply to records for the deceased.

NHSE/PCSE would become the record holder of the deceased’s records at the point at which we physically take possession.

Practices remain legally responsible for copies of records retained on local systems. Where a practice retains a copy (be it paper or electronic) of a deceased patient’s record, they are legally obliged to consider it under AHRA. They may choose to direct applicants to PCSE, but must also be prepared to respond directly if an applicant insists on accessing data retained by the practice.

PCSE will consult an appropriate health professional who will review the records and decide which records may be released.

There are certain circumstances in which the health professional may deny access to the complete records or to certain parts of the record:

  • The Health Professional has deemed notes not suitable for disclosure, as they are not within the scope of the request.
  • Where an individual other than the patient (and appropriate health professionals) could be identified from the information (unless the individual consents).
  • The deceased person stated that they did not wish for any part of their records to be released after death, or the information contained within the records was such that the deceased person expected them to remain confidential.
  • Access cannot be given to records made prior to November 1991.

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