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									               POLICY AND PROCEDURE FOR

               ACCESS TO HEALTH RECORDS




This Policy and Procedure
was formally approved by Doncaster &
South Humber Healthcare Trust


Date: …………………………..


Signed: ………………………
Chief Executive


Issued June 2001


        POLICY AND PROCEDURE FOR ACCESS TO HEALTH RECORDS


INTRODUCTION

The Access to Health Records Act 1990 gives the right of access to health information of
deceased patients from 1 November 1991. The Data Protection Act 1998 gives a “data
subject” the right of access to personal data including manual health records, automated
records or a combination. The purpose of this document is to affirm the Trust’s commitment
to enable individuals or persons acting on their behalf (see “Declaration” at Appendix A ) to
obtain access and to outline the procedure for access which will apply in all cases.
OBJECTIVE

To ensure and maintain the individuals right of access to their health care records subject
only to the exemptions outlined in paragraph 7 of the procedure, which follows.

PROCEDURE FOR ACCESS TO HEALTH RECORDS

1.     In the first instance, Record Managers should attempt to assist people seeking
       access to their Health Records to gain access on an informal basis in liaison with the
       Health Professional involved. Only if this is impossible should the Access to Health
       Records Act and/or The Data Protection Act be invoked.

2.     Formal requests for access should be directed to the Data Protection Officer at
       Chestnut View, St Catherine’s.

3.     On receipt of the request, the Data Protection Officer should forward the official
       application form (Appendix A) to the applicant unless appropriate documentation
       accompanies the request. The Data Protection Officer will then complete part 1 of
       the Monitoring Form (Appendix B).

4.     On return of the official application form the Data Protection Officer will check the
       validity of the application, receipt the fee (if appropriate – see paragraph 14) and
       acknowledge receipt of the application. Part 2 of the Monitoring Form will then be
       completed.

5.     The Data Protection Officer will then forward the application together with the
       monitoring form to the appropriate Manager with responsibility for Records, i.e.

       Mental Health/Learning Disability Records (Doncaster) -    General Services Manager
       (including nursing and paramedical records)

       Community Records (Doncaster)                       -      Directorate Support
       (including nursing and paramedical records)                Co-ordinator

       Elderly/Specialist Records (Doncaster)              -      Clinical Manager
       (including nursing and paramedical records,
       excl. medical records)


                                                                                           1



       North Lincolnshire Mental Health                    -      Head of Service

       North East Lincolnshire Mental Health               -      Head of Service


       In the event that records sought are not held by the Trust, the applicant will be
       referred to the relevant staff in those health organisations which employ the
       clinicians who have recorded the applicant’s care. This situation may arise as a
       consequence of multidisciplinary working which entails members of different
       health organisations contributing to the care of a single patient.
6.    The appropriate Records Manager will make an appointment with the lead health
      professional to discuss disclosure.

      If the appropriate health professional is not available or has not had clinical
      responsibility for the patient, the Records Manager should seek advice of the health
      professional who seems most appropriate to advise on the application, e.g. another
      doctor or dentist, a nurse or paramedic.

7.    The lead health professional should advise on:

      a)     Whether access should be allowed or limited to prevent (i) the disclosure of
             seriously harmful information or (ii) the identification of third party
             individuals.

      b)     Whether in connection with an application to a child’s records, the child is
             capable of understanding the nature and purpose of the application.

      c)     Whether access would be in accord with the best interest or wishes of the
             patient.

      d)     The non-retrospective provisions of The Access to Health Record Act 1990
             largely precludes whether access to records preceding 1 November 1991, do
             not apply to the Data Protection Act 1998.

      e)     Whether the applicant should be allowed to inspect the record itself or
             should be shown an extract setting out so much of the record as is not
             excluded from access. If an extract is to be shown this must be prepared by
             the health professional.

      f)     Whether it is necessary for the health professional to be present when the
             record or extract is inspected (in order to provide any explanation or
             counselling) or if this can be supervised by the appropriate manager with
             responsibility for records.

      g)     Whether access should be given by posting the record or extract to the
             applicant together with any necessary explanation.

8.    The lead health professional may wish to authorise disclosure subject to agreement
      with other health professionals and may authorise the Records Manager to act on
      his/her behalf.
                                                                                       2
9.    The Records Manager should liaise with the other health professionals if requested
      and report back to the lead health professional as necessary.

10.   The Records Manager should make an appointment with the applicant and lead
      health professional, if appropriate, within the timescales laid down by the Acts, i.e.
      40 days for a non current record, 21 days for a current record.

11.   The Records Manager will arrange for a copy of the notes to be made available (if
      applicable) and for any fees to be collected. If copy notes are to be sent to the
      applicant, it should be by registered post.

12.   The Records Manager should complete part 3 of the Monitoring Form and place one
      copy in the notes and return a second copy to the Data Protection Officer for central
      collation.
13.       SUBSEQUENT ACTION

          a)      Any inaccuracies in the health record, reported by the applicant, should be
                  noted. If agreed by the lead health professional these inaccuracies should
                  be corrected.

          b)      An indication should be made in the health record regarding the amendment
                  made. Care must be taken not to obliterate information which may have
                  significance for the future care and treatment of the patient or for litigation
                  purposes.

14.       FEES FOR ACCESS TO HEALTH RECORD

          14.1    The Access to Health Records Act entitles the Trust to request a fee in
                  respect of any application for access to health records. The fee will be £10
                  for access to records which have not been added to within the last 40 days
                  plus any reasonable administrative charge eg photocopying.

          14.2    The Data Protection (Subject Access) (Fees and Miscellaneous Provision)
                  Regulations 2000 made under The Data Protection Act, set the fees for
                  giving access to health records. There are, however, transitional
                  arrangements which will apply to all requests until 24 October 2001. The
                  fee arrangements are as follows:

                      £50 maximum fee where the data subject is supplied with copies of manual
                       or a combination of manual and automated records in permanent form.

                      No fee where access (but no copies) is sought to a manual record, at least
                       part of which comprises a recent record (made within 40 days).

                      £10 for granting access to automated records.

                      £10 where access only (but no copies) is sought to manual records, none of
                       which comprise a recent record (all are over 40 days old).

          14.3    The transitional arrangements apply only to requests made before 24
                  October 2001. Thereafter it is expected that the £10 maximum fee will
                  apply to providing copies of health records.
                                                                                             3
                                                                                                 Appendix A
                      DONCASTER & SOUTH HUMBER HEALTHCARE NHS TRUST

                          APPLICATION FOR ACCESS TO HEALTH RECORDS
                              (ACCESS TO HEALTH RECORDS ACT 1990)
                                 (THE DATA PROTECTION ACT 1998)

Details of the applicant (if different from the patient details given below)

Surname           _____________________________                  Forenames ___________________________

Address           _________________________________________________________________________

                  _____________________________________________________________

Details of record to be accessed:
Hospital/Community/Paramedical/Other ________________________________________

Patient Details

Surname           _________________________                  Current Address

Forename(s) _________________________                        _______________________________

Date of Birth _______ / ______ / _________                   _______________________________

Hospital Ref No (if known) _____________                     _______________________________

NHS Number (if known)              _____________             _______________________________

Name of General Practitioner ________________________________________________

If your name and/or address was different from the above during the period(s) to which your
application relates, please give details:

Previous Surname           (1) _____________          (2) ____________         (3) ________________

Previous Address           ________________           _______________          ___________________

                           ________________           _______________          ___________________

Patient’s Hospital or Clinic Contact

Please provide as much information as possible. Give full details of all the episodes you are
interested in and if you only wish to receive data relating to a specific aspect of one or other
of these episodes, please specify in the comments section below.

Hospital/Clinic Attended   Dates     Ward or Clinic                   Name of health professional




                                                                                                          1
                                                                                                    Appendix A

GENERAL PRACTITIONER – If you or the person on whose behalf you are making this application, want
your/their GP to be informed that you/they have obtained copies of your/their Personal Health Data please
record the GP'’ name and address:                                                                         1
GPs Name ___________________________                  Address _________________________________

Comments          _______________________________________________________________________
                  _______________________________________________________________________
                  _______________________________________________________________________
                  _______________________________________________________________________
                  _______________________________________________________________________
Declaration      I declare that the information given by me is correct to the best of my knowledge and belief
                 and that I am entitled to apply for access to the health record referred to above under the
                 terms of the Access to Health Records Act 1990 and /or The Data Protection Act 1998
                 (Please identify your status – delete those below which do not apply)

                 * I am the patient

                 * I have been asked to act by the patient. The patient’s written authorisation to this effect
                 is set out below.

                 * I am acting in loco parentis and the patient is under the age of 16 years; and
                 (a) is incapable of understanding the request
                 (b) has consented to my making this request

                 * I am the deceased patient’s personal representative and attach confirmation of my
                 appointment

                 * I have a claim arising from the patient’s death and wish to access information relevant to
                 my claim on the grounds that:
                 _______________________________________________________________________
                 _______________________________________________________________________
                 _______________________________________________________________________

                 Signed ______________________________                   Date _______________________

Authorisation    I certify that I (Name of patient)   __________________________________________

                 of (Address) ____________________________________________________________

                 hereby authorise (Name of applicant) ________________________________________
                 to act on my behalf in respect of this application for access to my records.

                 Signed ______________________________                   Date _______________________

On completion this form should be forwarded to:

                 Data Protection Officer
                 Beech View
                 St Catherine’s
                 Tickhill Road
                 Doncaster
                 DN4 8QN

together with the fee payable if the record required has not been added to within the last 40 days. Please
make cheques payable to Doncaster & South Humber Healthcare NHS Trust. The Trust may also levy
reasonable administrative charges e.g. photocopying. You will be advised of such charges before your
request is processed.




                                                                                                                 2


                                                                                                       Appendix B



                   DONCASTER & SOUTH HUMBER HEALTHCARE NHS TRUST

                      ACCESS TO HEALTH RECORDS – MONITORING FORM

Name and Address of patient/client                    Name and Address of Applicant
                                                      (If different from patient)

____________________________________                  ____________________________________
____________________________________       ____________________________________

____________________________________       ____________________________________

Tel. Number _________________________      ____________________________________

Hospital ID ________________

PART 1

                                                         DATE       LATEST RESPONSE
                                                                    DATE
                                                                    1
REQUEST RECEIVED

OFFICIAL APPLICATION FORM SENT

PART 2

COMPLETED APPLICATION FORM RETURNED                                 2

APPLICATION VERIFIED           YES/NO

FEE COLLECTED                  YES/NO
RECEIPT NO:

APPLICATION ACKNOWLEDGED

APPLICATION FORWARDED TO RECORDS MANAGER

PART 3

LEAD HEALTH PROFESSIONAL CONTACTED

OTHER HEALTH PROFESSIONAL(S) CONTACTED

ACCESS AGREED/REFUSED          APPLICANT NOTIFIED                   3

APPOINTMENT MADE WITH APPLICANT (IF APPLICABLE)

COPIES OF RECORD SENT TO APPLICANT (IF APPLICABLE)

1        14 DAYS FROM DATE ACTIONED

2        2 WORKING DAYS FROM DATE ACTIONED

3        WITHIN 40 DAYS FOR NON CURRENT RECORDS
         WITHIN 21 DAYS FOR CURRENT RECORDS

                                                                                      1
Issued June 2001

								
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