ADVICE DISCLOSURE OF RECORDS
Need toknow
MDDUS solicitor Lindsey McGregor offers some basics on the disclosure of patient records
access to medical or dental records from various sources is a regular feature of general practice today. Patients, police, lawyers, social workers, insurance companies – the list is endless. And some requests can be quite unusual and the appropriate response not entirely obvious. At MDDUS our medical and dental advisers receive calls
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on a regular basis from practice managers or practitioners seeking advice on how to respond to such requests. We encourage members to get in touch with specific queries but it is helpful and important to have an overview of the legal framework behind records requests.
WHAT AND WHAT NOT TO DISCLOSE The Data Protection Act 1998 gives all patients the right of access to all computerised and manual records which contain information about their physical or mental health. This Act will be very familiar to many practice managers and stipulates a 40-day turnaround from the request being received in writing by the data controller. But what are you to give access to? In the legal team we sometimes are provided with records which have been recovered by patients and handed over to their solicitors to commence a claim. In those records we will see documents which should not form part of the clinical record and may in fact be prejudicial to a claim. Only disclose records of clinical relevance and do not include:
• correspondence with the MDDUS medical or dental adviser
• GMC/GDC correspondence • correspondence with solicitors/DVLA/insurance companies • case conference notes.
AUTHORITY TO DISCLOSE It’s also important to know who has made the request and if they are authorised to do so. Requests do not always come from patients and it’s important to check that the authorisation is valid and is signed and dated. In requests for access to children’s records, check that the person making the request has parental rights. Generally speaking parents can exercise their parental rights and responsibilities without the consent of the other parent and this would include access to records. However, some parents have had their rights restricted or removed and it’s important to check that the request is valid. This is partic- ularly the case with unmarried parents. If the father’s name is not on the birth certificate and he has not been granted parental rights by agreement or by court order then he is not entitled to have sight of his child's records. Equally important is to consider the age of the child as he or she may be legally competent to consent to the release of the records.
O DISCLOSE or not to disclose – that may be the question but what’s the answer? Deciding how to comply with the numerous types of requests for
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SUMMER 2011ISSUE 4
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