Wherever you visit an NHS service in England a record is created for you. This means medical information about you can be held in various places, including your GP practice, any hospital where you've had treatment, your dentist practice, and so on. Also read our section about different types of health records.
What is in a health record?
A health record (sometimes referred to as medical record) should contain all the clinical information about the care you received. This is important so every healthcare professional involved at different stages of your care has access to your medical history, such as allergies, operations or tests. Based on this information, healthcare professionals can make judgements about your care going forward.
Your health records should include everything to do with your care, including x-rays or discharge notes. The data in your records can include:
- treatments received or ongoing
- information about allergies
- your medicines
- any reactions to medications in the past
- any known long-term conditions, such as diabetes or asthma
- medical test results such as blood tests, allergy tests and other screenings
- any clinically relevant lifestyle information, such as smoking, alcohol or weight
- personal data, such as your age, name and address
- consultation notes, which your doctor takes during an appointment
- hospital admission records, including the reason you were admitted to hospital
- hospital discharge records, which will include the results of treatment and whether any follow-up appointments or care are required
- X-rays
- photographs and image slides, such as magnetic resonance imaging (MRI) or computerised tomography (CT) scans
Find out how long medical records are kept.
Confidentiality
There are strict laws and regulations to ensure your health records are kept confidential and can only be accessed by health professionals directly involved in your care. There are a number of different laws that relate to health records, the two most important laws are:
Under the terms of the Data Protection Act (1998), organisations such as the NHS must ensure that any personal information it gathers in the course of its work is:
- only used for the stated purpose of gathering the information (which in this case would be to ensure that you receive a good standard of healthcare)
- kept secure
It is a criminal offence to breach the Data Protection Act (1998) and doing so can result in imprisonment.
The Human Rights Act (1998) also states that everyone has the right to have their private life respected. This includes the right to keep your health records confidential.
Your health, your choices