Health records

Health records contain information about your health and any care or treatment you've received.

Your health records may contain:

  • test and scan results
  • X-rays
  • doctors notes
  • letters to and from NHS staff

It’s important that your records are kept up to date. You should tell NHS staff when your personal information changes or if you are going to be out of the UK for a long time.

How health records are stored

Different parts of the NHS hold records. For example, your GP surgery and any hospital you have been to may hold records about you.

The NHS has guidelines about how long it should keep health records, after which they can be destroyed.

You should contact your GP practice manager or hospital health records manager if you would like more information about how your records are stored.

Emergency health records

Most patients in Scotland now have an Emergency Care Summary containing basic information about your health in case of an emergency.

NHS staff can also use your Emergency Care Summary if your GP refers you to an outpatient clinic or for admission to hospital to check your details.

Before any member of staff looks at your Emergency Care Summary, they must get your consent. If you are too unwell to give consent, they may need to read your Emergency Care Summary without your agreement in order to give you the best possible care.

The Scottish Government provide more information about the Emergency Care Summary in the leaflet – Your Emergency Care Summary – What does it mean to you?

Specialist health records

Patients with particular needs or living with long-term conditions may also have a Key Information Summary containing information that NHS staff should know.

The Key Information Summary might contain:

  • an emergency contact
  • information about a patients condition
  • what treatment the patient is having

If you need a Key Information Summary, your GP will discuss with you what information should be included.

NHS 24 provide more information about the Key Information Summary.

Accessing your health records

You have the right to see or have a copy of your health records if you want to know more about treatment that you've had or check that your information is correct.

How to see your records

To see your records, you will have to apply in writing to the practice manager at your GP and dental surgeries and records manager at hospital.

You don't need to give a reason for wanting to see your health records.

When writing, you should say if you:

  • want a copy as well as to see them
  • want all or just part of them
  • would like your records to be given to you in a format that meets your needs

You may also need to fill in an application form and give proof of your identity.

Who can apply?

You can usually apply if you're able to understand what is involved in asking to see your records.

Someone else can apply to see your records if you:

  • agree to this
  • lack capacity and someone has been appointed to act on your behalf

Find out more about making decisions.

Young people

Someone with responsibility for you can apply to see your records, but only if:

  • you agree to this
  • and you don’t understand what is involved

Find out more about young people and consent.

Cost to view your records

The cost to view your medical records is as follows:

Records added Cost
Within 40 days Free
More than 40 days ago Up to £10

You will always be told the cost before you make a decision.

Cost to copy your records

The cost to copy your medical records is as follows:

Records held Cost
On computer Up to £10
On paper Up to £50
On computer and paper Up to £50

You will always be told the cost before you make a decision.

How long will it take

You will usually receive your records within 40 days of making an application and paying the cost.

Unhappy with your application

If you are unhappy with how your application has been dealt with, you should ask to speak to the person that received your application.

If you are still unhappy, you have a right to make a complaint.

Find out about giving feedback and making complaints about how your application has been dealt with.

Viewing your health records

If you choose to view your records at your GP surgery or hospital, someone will probably be with you while you do this.

If you choose to be given a copy, you may get a computer printout or a photocopy.

Discretion

Some information on your records may be kept from you. NHS staff don't have to tell you if this has happened.

You won’t be able to see information that could:

  • cause serious harm to your own or someone else's physical or mental health
  • identify another person (except NHS staff who have treated you), unless that person gives permission

Incorrect information

If you think information in your records is incorrect, you should first talk to staff providing your care who will then decide the best course of action.

If they decide the information is incorrect:

  • A line will be put through it so that people can still read it but can see that it has been corrected
  • A note will be attached to your records explaining why this has been done

If they decide the information is correct:

  • Your records will not be changed
  • A note can be attached to your records explaining why you think the information is incorrect

Removal of information

Information can only be removed from your records if a court orders it or amended at the request of the Information Commissioners office.

NHS staff need your full records to understand earlier decisions made about your care and treatment.

Compensation

You can claim compensation if you suffer physical, psychiatric, or financial damage because:

  • information in your records is inaccurate
  • your information is accidentally lost, damaged or destroyed, or disclosed without permission

Find out more about clinical negligence and your right to feedback and complain about your care.

Deceased records

The law allows you to see records of a patient that has died as long as they were made after 1st November 1991.

Records are usually only kept for three years after death.

Who can access deceased records?

You can only see that person’s records if you are their personal representative, administrator or executor.

You won’t be able to see the records of someone who made it clear that they didn’t want other people to see their records after their death.

Accessing deceased records

Before you get access to these records, you may be asked for:

  • proof of your identity
  • proof of your relationship to the person who has died

Viewing deceased records

You won’t be able to see information that could:

  • cause serious harm to your or someone else's physical or mental health
  • identify another person (except members of NHS staff who have treated the patient), unless that person gives their permission

If you have a claim as a result of that person’s death, you can only see information that is relevant to the claim.