Access to health records

Medical records

Everyone working for health and social care services has a legal duty to keep information about you confidential.

This page explains why we ask for your personal information, how that information will be used and how you can see your health and social care record.

Why is information recorded about me?

Your doctor and other health or social care professionals caring for you keep records about the treatment you receive. They may be written down (manual records), or kept on a computer (electronic records).

These records may include:

  • basic details about you, for example, address and next of kin
  • contacts we have had with you, for example, appointments
  • notes and reports about your health and care, for example, change in medication or family circumstances
  • details and records about your treatment and care, for example, advice given or referrals made
  • results of investigations
  • relevant information from people who care for you and know you well, for example, social healthcare professionals and relatives.

What is the information used for?

Your records are used to ensure that we provide you with the best possible care.

It is important that your health and social care records are accurate and up-to-date as they will help make sure that any staff who are looking after you are able to provide you with the care you require.

Your records will also aid us with any investigation should you have a problem or concern regarding your treatment.

We may also use your information to improve the services we provide to you through audits and monitoring, to pay the care provider for your treatment, aid health research and help to teach healthcare professionals.

Will this information include personal details?

On the rare occasions where it is essential to include personal identifiable information, we will ask for your consent before this information is shared.Some of your personal information may be used for statistical reporting purposes. These reports may also be passed to organisations involved in health and social care research, for example universities. Occasionally an independent audit (check) will take place to make sure your information is being recorded and stored accurately and securely.

When other agencies are involved in your care, we may need to share details about you to enable us to work together for your benefit. Information will only be shared with them if they have genuine need for it and where possible we will ask for your consent for this.

Occasions when your information needs to be disclosed (given) include:

  • where the health and safety of others is at risk
  • when the law requires us to pass on information under special circumstances
  • when approved by the Secretary of State for Health

If there is information you do not wish us to share, please advise one of your health or social care professionals involved in your care.

Anyone who receives information from us has a legal duty to keep it confidential.

We are required by law to report certain information to appropriate authorities. This is only provided after permission has been given by a qualified health professional.

Occasions when information must be passed on include:

  • birth notification
  • where we encounter infectious diseases which may be a public health concern, for example, meningitis and measles (but not
     HIV/AIDS)
  • where a formal court order has been issued

Partner organisations

We may share information with organisations where they contribute to your health and care.
These could include:

  • Your GP surgery and other NHS organisations
  • Audit organisations
  • Department of health
  • Clinical networks eg cancer care

We may also share some of your information subject to strict agreement on how it will be used with:

  • local authorities and education services
  • voluntary or private care providers
  • police and coroner’s office.

Can I see my health and social care record?

The Data Protection Act 1998 allows you to find out what information is held about you, on computer and in certain manual records. This is known as “right of subject access”, and applies to your health and social care records.

If you want to see a copy of your health records you should contact a member of staff from the Patient Access Office at the James Cook University Hospital on 01642 854460 who will be able to advise you further. You are entitled to receive a copy of your records but should note that a charge will usually be made.

In certain circumstances access to your records may be limited, for example, if it is felt to be in your best interest or for the protection of others.
Further information.

If you would like to know more about how we use your information or if, for any reason you do not wish to have your information used in any of the ways described, please speak to the health or social care professionals concerned with your care. You can also write to the data protection officer of the NHS or Social Services organisation from which you receive, or have been receiving treatment or services.

For South Tees Hospitals NHS Foundation Trust this is the head of information governance who can be contacted on 01642 854291 or at IG.Advice@stees.nhs.uk

Further guidance about data protection can be obtained from the Information Commissioner website.

Patient access service

Under the Data Protection Act 1998, patients or their representatives are entitled to request copies of the patient’s own health record. All applications to see health records must be made on the trust’s access to health records form which is available from the patient access office on 01642 854460 or can be downloaded using the link below.

Application form (80kb)
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Once complete, please return these forms to:

Patient access office supervisor
Legal and risk department
2nd Floor
Murray Building
The James Cook University Hospital
Marton Road
Middlesbrough
TS4 3BW
Tel: 01642 854460
 

Your health and social care record (174kb)
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