Accessing Medical Records
In most countries it is your right to access your medical records. This page provides a general overview of why you may want your medical records and how you can request them. Although this resource is not country specific, we hope it gives you an idea of how to start the process.
What are Medical Records?
Medical records provide information on your medical history such as detailed information on hospital admissions including tests, results and medications. Every time you see a doctor or other health care practitioner the details of that meeting will be recorded in your records. Historically, records were written on paper and stored in hospitals. However, in many places they are now being made electronic.
Why do I Need my Medical Records?
Medical records are useful especially if you are changing doctors, being referred to a specialist or asking for a second opinion. Although doctors at different hospitals will have an overview of a patient’s case, they may not have access to all the records, so being able to share your records with them will allow them to get a full picture of the case.
How do I Access my Medical Records?
In most countries it is a patient’s right to request copies of their medical records. The process for accessing medical records varies but in most cases a request must be made directly to the health care provider (i.e. your hospital). Each hospital you have been treated at will have records specific to your time there. If you were treated at more than one hospital you must request records from each hospital you have been treated at. In the UK this process is known as a Subject Access Request (SAR) and many hospitals have forms to support this process.
It is recommended to talk to your medical team to initiate the process of accessing medical records.
Can I Access Someone Else’s Medical Records?
If you request another person records, you will either need to show that the person has consented or that, by law, you have the rights to make decisions on their behalf if they lack capacity. Capacity is the ability to understand, make and communicate decisions.
Teenagers are usually considered to have capacity and therefore would need to consent to allow their parents to access their records.
Can I Access to my Medical Records be Refused?
Access to parts of a medical records can be denied if the content may cause harm or relates to another person.
“It’s that connection between the patient and the team and myself and also the interplay between looking after a teenager and their parents and the rest of the family I found really rewarding”
Dr Sandra Strauss, UCL
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