What is a medical/health record?

Wherever you visit an NHS service in England a record is created for you. This means medical information about you can be held in various places, including your GP practice, any hospital where you’ve had treatment, your dentist practice etc.

A health record (sometimes referred to as medical record) should contain all the clinical information about the care you received.

This is important so every healthcare professional involved at different stages of your care has access to your medical history, such as allergies, operations or tests. Based on this information, healthcare professionals can make judgements about your care going forward.

Paper and electronic records contain:

• treatments received or ongoing
• information about allergies
• your medicines
• any reactions to medications in the past
• any known long-term conditions, such as diabetes or asthma
• medical test results such as blood tests, allergy tests and other screenings
• any clinically relevant lifestyle information, such as smoking, alcohol or weight
• personal data, such as your age, name and address
• consultation notes, which your doctor takes during an appointment
• hospital admission records, including the reason you were admitted to hospital
• Hospital discharge records, which will include the results of treatment and whether any follow-up appointments or care are required
• X-rays
• Results of other tests and investigations

Access to Health Records governed by Data Protection Act (1998)

Some GPs have given online access to their patients’ GP records for some time. From April 25th 2015 all GPs have been expected to give their patients online access to summary information in their records. This is part of the drive to provide more GP online services to patients. It should give you more control of your health and well-being, especially if you are managing a condition that needs regular monitoring and frequent prescriptions.

• If you want to view medical records held by other NHS services you need to make a formal request under the Data Protection Act (1998) and apply in writing to the holder(s) of the records.
• If you wish to view your medical records online please sign up at Reception (you will need to provide photo ID)
• If you wish to see a paper version, please write to your GP or the Practice Manager.
• If you want to see your hospital records, write to the hospital’s Patient’s Services Manager or Medical Records Officer.

If you think that information in your health records is incorrect or your need to update your personal details (name, address, phone number), please contact the practice in writing and let us know what needs changing.

We cannot change clinical records that have been previously recorded, although we can add supplementary comments if you wish to clarify statements that have been made (especially if you disagree with them).