Your health records

To download a pdf leaflet of this information.

This page is a guide to the information we hold about your health and how we access this information. It covers your rights, what you need to do and who to contact if you have any questions.

The National Health Service (NHS) aims to provide you with the highest quality of health and social care. To do this, we must keep records about you, your health and the care we provide or plan to provide.

The NHS is undergoing a transformation in the way that patient information is held, managed and accessed with the introduction of the NHS Care Records Service. This will give the staff that are treating you faster access to reliable information about you, which is very important in an emergency. It will also give you better access to this information, helping you to manage your own health.

• What information is kept about me?
• Why do I need to supply this information?
• How are my records kept?
• What are my records used for?
• What rights do I have?
• Can parents or legal guardians see their child’s records?
• How will Electronic Health Records work?
• How secure is the access to my information?
• What action do I need to take?
• Where can I get more information?

What information is kept about me?

We keep information about you so that we can provide you with safe, fair and effective care. The information we may keep includes:

• Name
• Address
• Contact details
• Place and date of birth, sex ,age and NHS number
• GP
• Next of kin
• Ethnicity, disability and first language.

The information we keep about your health will include:

• Your medicines and any adverse (bad) reactions
• Any allergies you may have
• Health conditions such as asthma or heart problems
• Reminders for healthcare staff about future plans for your care.

Why do I need to supply this information?

Having this information helps us to make improvements to services. It helps us understand your needs and if we are directing our services
to the right people in the right places.

How are my records kept?

As we complete our move to the NHS Care Records Service, patient records and data (information) will be held electronically. Before this, the majority were held as paper records.

Only details that may be relevant to your future healthcare will be transferred from your paper records to your electronic records. No retrospective (past) full transfer of information will take place.

Your old paper records will be kept for the required time, set out by the Department of Health, before being destroyed under confidential conditions.

What are my records used for?

The people caring for you use your information (paper or electronic) to provide treatment, check the quality of your care, help you make good decisions about your health and to investigate complaints and claims.

We sometimes use your information to:

• Check the quality of care we provide to everyone (a clinical audit)
• Protect the health of the general public
• Monitor how we spend public money
• Train healthcare workers
• Carry out research
• Help the NHS plan for the future.

If we use your information for these reasons, we will remove your name and other details which could identify you. If we need the information in a way that identifies you, we will ask you first.

In very limited circumstances, the law allows us to use your information without asking you first. In all cases we will only provide the minimum of information needed and will, wherever possible, tell you. Examples of this use of information are to:

• Tell authorities about the birth of a child
• Report food poisoning cases to the authorities
• Report some infectious diseases
• Provide information to be used in court
• Give information to the police to help detect or prevent a crime.

We promise to:

• Keep full and accurate records about the care we provide you.
• Keep your records confidential, secure and accurate.
• Hold and dispose of your records securely.
• Make sure that your records are not kept any longer than they need to be.
• Make sure that your records are only shared amongst the people providing your healthcare and who need to know.
• Make sure that we do not share information which identifies you outside of the health service:
  • unless you say we can
  • we have to by law
  • if others could be put at risk if we did not share the information.
• Provide you with information relating to your records, if you ask for it in writing. We cannot give you confidential information about other people or provide information if a healthcare professional believes it could cause physical or mental state harm to you or another person.
• Make sure that everyone who sees your records are trained and understands that they must keep them confidential.
• Take appropriate action against anyone who looks at your records without permission or with good reason.

What rights do I have?

• Confidentiality under the Data Protection Act 1998, the Human Rights Act 1998 and common law duty of confidence.
• To ask for a copy of all records held about you (there may be an administration charge for providing these).
• To ask for a list of everyone who has looked at your records and when.
• To stop your information being used by organisations to contact you and promote services or goods.
• Ask for compensation if you suffer as a result of a breach (break) of confidence.
• Under current law, only you can make decisions about the sharing of your health information. The exception to this is parents or legal guardians of children or people with powers under mental health law. If you decide that you do not want your information shared, this may have an effect on your healthcare. Your healthcare professional will be able to discuss this with you.

Can parents or legal guardians see their child’s records?

Currently, parents or legal guardians have the right to have access to their child’s records, if their child is under 16.

Their child has the right to ask us not to give their parent or guardian access to their records. Their child also has the right to give information to us and to expect that access to that information will not be given to their parent or guardian.

However, even if a child has asked us not to give access, we may give parents and legal guardians information if the reasons for giving them access are more important for public good than keeping the child’s information confidential. This will still be the case with the NHS Care Records Service.

How will Electronic Health Records work?

As we progress with the roll-out of the electronic NHS Care Record
Service, we will create a Summary Care Record for you. In the future
we will add more detailed electronic records.

Summary care record

• Your Summary Care Record will be able to be accessed by authorised healthcare professionals treating you anywhere in England.
• At first it will include basic details from your GP record covering allergies, current prescriptions and bad reactions to medicines.
• Each time you use an NHS service, information may be added about your current health problems, the care you are receiving and the healthcare staff treating you.
• As new information is added, you can discuss this with the healthcare staff treating you, particularly how any sensitive information is handled (e.g. relating to mental or sexual health).
• Your healthcare staff will explain how the Summary Care Record works and how you can place limits on who can access your information.

Detailed records

• Instead of having separate records across all NHS organisations and locations, such as hospitals, clinics and GP surgeries, we hope to gradually link electronic records together to enable the staff caring for you to have direct access to the information they need.
• If you have any concerns about the sharing of information you can raise these during your consultation or with the NHS Norfolk Patient Advice and Liaison Service.
• Your detailed records will contain:
  • your name, address, date of birth and NHS number.
  • details of any medicines you are taking (or have taken, allergies, test results and X-rays).
  • details of any health conditions.
  • notes of any diagnoses, treatments or operations.
  • plans or reminders for your care in the future.

We will link your detailed records over several years and you will be informed about this as it happens.

How secure is the access to my information?

All health records are private and personal. The NHS Care Records Service will use the strongest national and international security measures for handling your information. Every Patient registered with the NHS has a unique NHS number. We use this to link all of your information together and to make sure we place it onto the right record.

Anyone wanting to look at your healthcare records must:

• Be involved in caring for you
• Have a security NHS Smartcard with a chip and pass code
• Only see the information they need to do their job
• Have their details recorded (who they are and what they have done with your record).

What action do I need to take?

• Tell us if any information we hold about you is wrong.
• Let us share as much of your information as we need to so that we can provide you with effective health and social care.
• Be careful who you show your medical records to and only show the information that is needed (e.g. solicitors, etc).
• Tell us immediately if you change you mind about the sharing of your health records.

Where can I get more information?

If you would like more information or would like to see your health records, talk to the person who is caring for you.

You can also contact the NHS Norfolk Patient Advice and Liaison Service (PALS) who will put you in contact with the appropriate person to help answer your questions:
Tel: 0800 587 4132
Mobile: 07500 990815
Email: pals@norfolk.nhs.uk  

The NHS Care Record Guarantee for England is a more detailed version of this leaflet which you can order from the NHS Care Records Service Publications Order Line on 08453 700 750. Alternatively, you can download a copy from www.nhscarerecords.nhs.uk