Policy on Access to Clinical Records

The practice is aware of ‘Access to Health Records 1990’ which came into force on 1st November 1991. This establishes a patient’s right of access to normally held medical records, and provides for inaccurate medical records to be corrected on the behalf of the patient.

Application for Access:

This may be made by;

• the patient
• a parent or guardian (in the case of a child)
• or, where an adult is incapable of managing his own affairs, any individual appointed by the Court to manage those affairs.
• by the patient’s personal representative after the patient’s death

After an application has been made:

Patients have a right to view their notes without charge. Requests should be made directly to the therapist in charge of the case. The therapist will arrange an appropriate time for the patient to see the records when they are available to explain any terms necessary (within 2 weeks). If the patient wishes the physio to interpret their notes with a face to face meeting this may be charged at usual appointment rates.

If the patient requests a copy of the records, they will be charged a reasonable photocopying fee.

The notes themselves remain the property of the therapist and do not leave the clinic.

If the patient requests corrections to any information:

If the therapist agrees to the correction, the notes are corrected accordingly.

If the therapist does not agree to the correction, a note of the applicant’s opinion must be included in the record (and copied to them).

Any queries with regard to this policy should be addressed to the Practice Principal.

Lorna Short
August 2010