Medical records and your rights

Doctors have a duty to keep proper medical records. Medical records relating to your care must also be kept confidential by GPs and hospital staff. However, you are entitled to get access to the records and can do so in several ways.

You can simply ask your doctor to see the records. You can secure the information under the Freedom of Information Act, under the Data Protection Act or through legal action.

The law relating to medical records is ill defined. Health authorities may argue that the actual medical records are the property of the doctor or the hospital. Much depends on whether your contract is with a doctor or a hospital or clinic.

However, the information contained in the records is information that is the rightful property of the patient. For example, should the patient wish to change doctor, the information in the records would be needed for their continuing care.

Under the Freedom of Information Act you can secure your records from public hospitals but this legislation does not cover private hospitals.

A doctor may refuse to disclose information in medical records to a patient, if he feels that this could cause serious harm to the physical or emotional well being of the patient. In such cases, the patient may request that the information be disclosed to a nominated person Ė for example another health professional.

Where a patient is deceased, access to medical records may be provided to a person who is administering the estate of the deceased, or the spouse or next of kin.

Confidentiality

The key principle for doctors under Medical Council guidelines is that they must not disclose information about your care or illness to any other person, without your consent. A doctor who breaches confidentiality can be reported to the Medical Council and may face a hearing into his or her conduct. Confidentiality is the cornerstone of medical care.

This rule does not apply however, when the information is needed by a court of law. A doctor may also need to disclose details of a patientís care if it is in the patientís best interests or if an infectious disease is involved and must be reported. In other rare instances, a doctor may feel he must disclose something that a patient has told him during a consultation - to protect a third party.