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INFORMATION & ADVICE - Access to Health and Social Care Records
 

The Data Protection Act 1998 (DPA) gives you the right to see all personal data held about you by any organisation. This includes (with some exceptions) information contained in all manual and electronic health and social care records, whenever it was recorded. The DPA places the onus on Data Controllers (Health and Social Services) to make it as easy as possible for service users to access their records.

There are only two situations in which a request to see your mental health records can be refused:

If in disclosing the personal data, information about another person or "third party" is revealed without their giving permission for you to see it.

Where permitting access to the data would be likely to cause serious harm to the physical or mental health of the person to whom it refers or to any other person.

These are the only circumstances in which information can be withheld. In all others, the law gives you access to your records. You also have the right to ask for copies of part or all of your records, although you may be charged for this service.

What Records are kept ?

Any contact with mental health services potentially will generate a record of that contact, which may then be kept for many years. These records may exist as paper files or increasingly as electronic data. Herefordshire Social Services routinely keep all mental health records for five years after last contact and the Primary Care Trust (Health Service) may keep them for up to 26 years.

All mental health professionals are required to keep records of their contact with service users and traditionally have done so in separate files. While the trend is increasingly for everone to record in a joint file, your past mental health records may be kept in several different places depending on which part of the service you have seen. So if you want to see everythng written about you, you will probably need to look in several different places:

Mental health information may exist in files kept by :

CMHT (community nursing and occupational therapy)

Medical (in-patient and out-patient)

Social work

Hospital Nursing (ward nursing staff)

Day Hopital

Psychology

GP

Additionally personal details and records of your contacts with health and social care staff are kept on several different computer systems. Some of this data is anonymised and used by managers for monitoring and planning services. You have the same right to see electronic information personal to you as that contained within traditional paper records.

How do I get to see them ?

A request for access to your mental health records should be made in writing to either:

your Care Coordinator

the Mental Health Services Manager 01432 355444

Mental Health Team Manager - 01432 266384 (for Social Work records)

On receipt of your request the Data Controller (Primary Care Trust or Social Services) has 40 days in which to arrange access or give a reason why access is denied.

During that time the data controller is responsible for checking through your notes for any information about "third parties" and if possible gaining permission for you to see it . Your notes will also be checked for any information that might be considered injurious your mental or physical health and that information may be withheld.

When this is done you will be invited in to view your notes. You should be provided somewhere quiet and private to read them. Your Care coordinator or someone nominated by him/her should be available to explain any thing you do not understand.
You are not allowed to take the file away with you but can have copies of its contents made although you may be asked to pay for these.

What if I don't agree with what is written ?

If you don't agree with what is written about you in your notes, you can ask that your disagreement be recorded in them and/or request that they be corrected. Ultimately if you cannot come to an agreement over an amendment you can apply either to the Courts or to the Data Protection Commissioner for your notes to be corrected or the offending material to be erased.

Data Protection Commissioner
Wycliffe House
Water Lane
Wilmslow
Cheshire
SK9 5AF

Tel. 01625 545 700