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Your health record
Accessing your record| | Subject Access Requests|
A health record is a collection of information that is unique to the individual patient. It ensures that the patient is correctly identified and that they receive the right treatment.
Examples of information stored within a health record are:
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hypersensitivity reactions to medicine
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test results
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information relating to inpatient and outpatient attendances
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nursing records
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drug charts
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correspondence from health care professionals involved in your care
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living will instructions
This information can be recorded and stored in a number of formats: paper, scans, microfiche and computer (electronic). These records are stored across the Trust in secure storage areas or libraries; the largest library is located on the John Radcliffe site.
The Oxford Radcliffe Hospitals NHS Trust has a legal obligation to ensure that records are kept for all patients who are treated within the Trust.
Who has access to your health record?
You do
In March 2000 the Data Protection Act 1998 came into force. This replaced the Access to Health Records Act 1990, except in the case of deceased patients. It allows patients, or their duly authorised representative, access to their health records, both on paper and in electronic format.
Our staff and other healthcare professionals
All staff working in the NHS have a legal duty to protect the confidentiality of the information that we hold about you.
Apart from the staff caring for you within the Trust, we may have to share information about you with other healthcare professionals involved with your treatment. This may include your GP, dentist, health visitor or community nurse.
If you would like to view your records whilst you are an inpatient within the Trust, please ask a staff member from your ward to contact the Access to Health Records Team, who are trained to assist with these requests. This team is located in the health records department of the John Radcliffe Hospital.
Requesting your health record after you leave hospital
If you would like to see your health record after you leave hospital, or if you would like copies of your health record, you will need to send a written request called a 'Subject Access Request'.
For further information, or to request a Subject Access Form for completion, please contact the team:
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Access to Health Records Team
Health Records Department
Level 0, John Radcliffe Hospital
Headley Way
Headington
Oxford OX3 9DU
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Tel: 01865 221516 / 221621 / 221856
Email: brenda.whyte@orh.nhs.uk
When completing your form or written request, please tell us clearly who you are and how you can be contacted.
You may wish to obtain all or parts of your health record relating to specific care dates, or sections of your health record. Requests should then be sent to the Access to Health Records Team.
Applications for Subject Access Requests from Solicitors or Insurance companies in relation to third party personal injury claims require written consent from the patient before records can be disclosed. These requests are processed by the Access to Health Records Team.
Subject Access Requests for the copying of records in potential clinical negligence claims and potential employers/occupational liability claims are processed by the Trust's Legal Department, who are located on the John Radcliffe Hospital site.
For further information please contact:
Further useful information
A healthcare professional may withhold access to information if, in their opinion, the release of the information might cause serious harm, or if third parties could be identified as a result.
Applicants have the right to an explanation of any technical language or terminology that they do not understand.
Should the applicant feel that something is wrong in the health record they have the right to request a correction, and are entitled to a copy of that correction. If the Trust refuses their request for a correction, the applicant must be given an explanation for that decision. The request, and the reason for the refusal, must be added to the health record.
Holders of records are obliged by law to be satisfied that an applicant is entitled to access the requested records. This may involve verification of identity and in some circumstances further enquiries and documentation may be required.
There is a fee for requesting records, dependent on record type (paper/electronic/x-ray) and number of copies. This fee ranges from a £10.00 minimum charge to a maximum charge of £50.00.
The Electronic Patient Record
In November 2011, the Oxford University Hospitals NHS Trust will be implementing a new clinical information system called Cerner Millennium. This system is commonly referred to as the Electronic Patient Record (EPR), and is comprised of a series of software applications which bring together key clinical and administrative data into one place.
The system is going live in phases. In phase 1, over the weekend of Saturday 26 November, the Emergency Department and Maternity systems will be implemented, along with a replacement patient information system. This will be followed by a three month bedding in period, to allow staff to familiarise themselves with the system and new ways of working.
Following this, in phase 2 increased clinical functionality will be rolled out across the Trust.
There are a number of benefits from implementing and EPR, not least the ability for clinicians to view a patient's medical record when and where they need it, without having to wait for the paper record to be brought or found.
Further benefits include the greater legibility of key clinical information and increased accuracy of data.
Patient confidentiality is also safeguarded through the strongest national and international security measures for handling information. Access to a patient's electronic record is only possible if you have a smartcard (which is like a chip and pin bank card) and a clinical relationship with the patient. Each time a patient's information is accessed, an electronic record of this is made.
To find out how this will affect you and your medical records, see the national NHS Care Records| website.