http://www.kirklees.nhs.uk/uploads/tx_galileodocuments/KPCT_Handling_Health_Record_Access_Requests__

Handling Health Record Access Requests

Eve Scott & Pat Patrice Prepared by:

Responsible Area:

Corporate Services Directorate Date Approved:

Approval Information: COMMITTEE:-

Approved By:

Reference to Standards for Better Health Domain

11th October 2007 Governance Group.

Sign

Director

Print Name

Director

Version No. Approved:

V1

Review Date:

October 2010

C9

Core/Development standard Performance indicators

History of Document

1. all access requests responded to appropriately 2. no adverse incidents regarding provision of health records

CONTENTS Section headings

Page

Introduction

3

Associated Policies and Procedures

3

Aims & Objectives

3

Access to Clinical Records

3/4

Refusing the request for access

4

Request to amend the content of a clinical record Right of Access to a Child’s Health Record Access To The Health Record of a Deceased Person

5 5 5/6

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1.0

Introduction This procedure lays out the process to be followed should someone request a copy of, or sight of, their health record. It is one of a set of procedures that underpins the Kirklees PCT’s Records Management Policy and as such must be complied with by all directly employed staff of the PCT. It is offered to the independent contractors as 'best practice' for them to use as appropriate in their sphere of responsibility.

2.0

Associated Policies and Procedures This procedure should be read and used in conjunction with the following policies and procedures:  Confidentiality Policy Statement & Guidance  Freedom of Information Policy  Incident Reporting Policy  Procedure for the Storage, Transfer and Tracking of Clinical Records  Procedure for the structure and format of a clinical record  Procedure for the 24 hour access to Clinical Records.

3.0

Aims & Objectives This procedure aims to ensure that all access requests are handled appropriately and that personal information is not disclosed to someone who does not have a right to that information.

4.0

Access to Clinical Records The DPA98, gives every living person the right to apply for access to his or her health records. The exception to this is the records of the deceased persons, which are still governed by the Access to Health Records Act 1990.

4.1

Any request for access to health records must be made in writing or electronically to the Records Manager. A fee can be charged for providing copies of health records, up to a maximum of:   

£10 + 15p per doubled sided photocopied page of paper records up to maximum of £50 £10 for a print out of computer records. £50 for copies of manual records or a mixture of manual and computer records.

4.2

The Act does not give applicants the right to directly inspect their health records, although this can, of course, be agreed between themselves and the Records Manager. However, it remains Department of Health policy that patients who wish to actually see what is written about them in their records should be allowed to do so, subject to some exemptions and unless there are compelling reasons to the contrary.

4.3

Any member of staff receiving a request for access to a health record must contact the Records Manager on Ex 6013 immediately to inform them of the request.

3

There is a limited time period of 40 days within which access must be given.

4.4

Individuals are entitled to apply for access to their whole health record as it was at the time the request was received by the PCT, without giving a reason for their request. However, it is more likely that they will only want to see part of the record, therefore it should be confirmed which aspects are required (''subject access request") and staff should help an applicant determine which part they need.

4.5

There is no obligation to comply with an access request unless the Records Manager has sufficient information to:   

identify the applicant locate the information or the required fee has been paid

This is to ensure that the record is only released to someone who has the right to it.

Once the XXXXXX has all the relevant information and fee, they must comply with the request promptly (within forty days of the request being made (DPA98), although the DoH advise 21 days maximum as a measure of good practice).

If, in exceptional circumstances, it is not possible to comply within this period the applicant must be informed.

4.6

On receiving a request in writing from an individual or their representative (in this case accompanied by a consent form signed by the data subject), the Records Manager should :  



5.0

log the application Check that the request does come from the data subject and that the requestor has the right to sight of the record. This is very important as patients have a right to have their personal health information kept confidential.

Inform the Director of Corporate Services should there be any indication that a Claim is being contemplated against the PCT.

Refusing the request for access There are certain circumstances in which the record holder may withhold information. Access may be denied, or limited, where:   

the information might cause serious harm to the physical or mental health or condition of the patient or any other person, giving access would disclose information relating to or provided by a third person who had not consented to the disclosure. an access request has previously been complied with, record holders need not respond to a subsequent identical or similar request unless a reasonable interval has elapsed.

NB: The decision to refuse access on the above grounds should be made by the lead clinician of that professional group within the PCT (eg Deputy Directors of Provider Services or their Deputy for Health Visitors, District Nurses etc).

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5.1

An explanation should be given to the individual as to why access to a part or whole of the record are being denied.

6.0

Request to amend the content of a clinical record If a patient feels information recorded on their health record is incorrect then they should firstly make an informal approach to the health professional concerned to discuss the situation in an attempt to have the records amended. If this avenue is unsuccessful then they may pursue a complaint under the NHS Complaints procedure in an attempt to have the information corrected or erased. They could further complain to the Information Commissioner, formerly the Data Protection Commissioner, who may rule that any erroneous information is rectified, blocked, erased or destroyed.

7.0

Right of Access to a Child’s Health Record A person with parental responsibility has right to apply for access to a child’s health record. However, where a child is considered capable of making decisions about their medical treatment, the consent of the child must be sought before a person with parental responsibility can be given access to their health record.

7.1

Someone with parental responsibility can be:   



The mother of a child The father of the child who was married to the mother at the time of the child's birth The father of the child who, although not married to the mother at the time of the child's birth, accompanied the mother to register the child's birth - this is applicable only to those births registered after Dec 2003.

The adoptive parents of a child.

NB; it is possible for a parent who is not living with the child because of separation or divorce to have parental responsibility for that child.

7.2

Situations in which access to the child’s health record can be refused Access can be denied in the following circumstances: 



8.0

If in the view of the appropriate health professional, the child patient is not capable of understanding the nature of the application, and access was felt not to be in the patient’s best interests. if an application is made by the parent of someone under the age of 16 who has the capacity and understanding to make their own decisions and does not consent to the release.

Access To The Health Record of a Deceased Person Access to the records of a deceased person falls within the remit of the Access to Health Records Act 1990. Legal advice may be needed regarding the release of the record of a deceased person.

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8.1

Any requests for access received by staff should immediately be referred to the Records Manager who must follow this process outlined below: 

  

   

Satisfy themselves that the applicant to the deceased patients health records is either an executor, administrator or anyone having a claim resulting from the death, eg by being given sight of the appropriate section of the deceased person’s will.

If not, write to the applicant requesting further information Log the applicant’s request Check the health records to see if the deceased patient had indicated that they did not wish for their information to be disclosed. Aim to comply with the request within 40 days of request.

In exceptional cases it may take longer than 40 days.

If so inform the applicant.

The applicant must be informed if the records have been destroyed after the recommended retention period.

Provide/deny the applicant with copies of the relevant parts of the health records. Alternatively, in agreement with the health professional, set a date for the applicant to view the relevant records once the relevant fee has been paid.

8.2

NB: the record holder has the right to deny or restrict access 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.

8.3

If the applicant is unhappy with any aspect of the process, try and resolve this locally. If this is not an option explain the PCT complaints procedure or instruct them to seek independent legal advice.

Document Title Document number Author Contributors Version Date of Production Review date Postholder responsible for revision Primary Circulation List Web address

Restrictions

Handling Health Records Access Requests TBC Eve Scott and Pat Patrice N/A V1 27th April 2007 April 2010 Records Manager All staff notified via team brief http://www.kirklees-pct.nhs.uk/publicinformation/publications/policies-and-procedures/informationgovernance/ None

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