Releasing
Patients' Notes/Patients' Rights under the Data Protection Act
The
right of access to personal data is described in the Data Protection
Act 1998 (DPA). It states that a Data Subject (i.e. the patient, or
the patient's nominated representative e.g. a solicitor) having submitted
a 'subject access request' (SAR) in writing and paid the appropriate
fee (see below), is entitled to be provided within 21 days* with a
copy of the Personal Data (i.e. the medical records/notes) held about
him or her. The Act requires that a copy of the data must be supplied
in permanent form unless the supply of such a copy is not possible,
would involve disproportionate effort, or the Data Subject (the patient
or solicitor) agrees otherwise.
The
general rights as set out in the DPA are modified by two orders. The
Data Protection (Subject Access Modification)(Health) Order 2000 provides
that information need not be disclosed if it would be likely to cause
serious harm to the physical or mental health of the Data Subject
or any other person and describes the mechanisms for ensuring that
decisions as to whether to disclose or withhold information are taken
by the appropriate health professional. The Data Protection (Subject
Access) Fees and Miscellaneous Regulations 2000 provides that whereas
the normal maximum access fee that may be charged is £10, for
health records a fee of up to £50 may be charged for paper notes
and £10 for computerised records. Providing information under
the Data Protection Act is seen as fulfilling a statutory duty, and
is consequently deemed to be outside the scope of VAT; so Practices
which are VAT registered should not add VAT to the fee.
*In
response to a ministerial commitment to Parliament, all NHS organisations
should endeavour to comply with subject access requests within 21
days, rather than the 40 days specified in the Data Protection Act
1998. The 21 day period starts as soon as both the request and fee
have been received by the Data Controller (i.e. the Practice).
There
is a draft Access to Medical Records Policy in the
Information Management & Technology index of the Members
Library. If
you are not a Member,
click here
for information about the benefits of membership and how to subscribe.
Charges
for providing information under the Data Protection Act are outside
the scope of VAT, so Practices which are registered for VAT should
not add VAT to such charges.
Practice
action upon receiving a request from a solicitor
If
the Practice receives a request from a solicitor, acting on behalf
of a patient, to provide a copy of the patient's medical records,
the patient's consent must first be obtained. A draft Consent Form,
together with guidance notes for the patient, the solicitor and the
Practice, can be downloaded from the BMA website - England
& Wales or Scotland
Guidance
from the BMA on access to health records by patients - 
Further
information
Department
of Health guidance on access to health records - 
NHS
Code of Practice: records management - 
Frequently
Asked Questions
Q.
Does the Data Protection Act 1998 mean that patients (not deceased)
can now have access to all of their records including those created
before Nov 1991?
A.
That's correct. Parts of the Access to Health Records Act 1990 have
been repealed and this Act now only applies to the deceased. Under
the Data Protection Act 1998, competent living patients or their representatives
can have access to their records regardless of when the record was
created.
Q.
Does the Data Protection Act (DPA) apply to records of deceased patients?
A.
No, the DPA does not cover the records of deceased patients. Rights
of access to records of deceased patients are set out in the Access
to Health Records Act 1990 and Access to Health Records (Northern
Ireland) Order 1993. In summary, any person (e.g. a personal representative,
executor or a dependant of the deceased) with a claim arising from
the death of a patient has a right of access to information which
is directly relevant to that claim. More details are set out on the
BMA website - go
there
Q.
Can we disclose records of a deceased patient to a GP who has now
left our employment and is the subject of a GMC complaint from the
family of the deceased patient?
A.
The following answer was given by the Medical Defence Union:
It is
important to note that the reason for the disclosure is not to benefit
the patient in any way. It does not relate to any ongoing medical
care, rather it is to benefit the doctor who is the subject of a complaint.
In these circumstances consent is needed.
In this
case the most sensible course of action would be for the GP who is
the subject of the complaint to request the medical records in the
usual way via the GMC. As part of the complaints process to the GMC
the complainants are informed of the need for disclosure of medical
records. They are also aware that they have complained to the GMC,
so the fact that the GMC are writing to them to request consent should
not be alarming to them.
You should
explain to your ex-employee that the Practice are not willing to disclose
copies of the medical records to him without consent, but that you
have been advised that the usual procedure is for the doctor via his
defence organisation to request copies of the medical records from
the GMC.
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