Accessing and disclosing medical records
Produced in partnership with Ian Huckstepp of IRH Solicitors
Accessing and disclosing medical records

The following PI & Clinical Negligence guidance note Produced in partnership with Ian Huckstepp of IRH Solicitors provides comprehensive and up to date legal information covering:

  • Accessing and disclosing medical records
  • Introduction
  • What is in the medical records?
  • When to obtain the records
  • Making the application for the records?
  • When can access be denied?
  • What charges are there?
  • Disclosure from a medical practitioner’s point of view
  • Access to a child or young person’s medical records
  • Access to the medical records of an incapacitated patient
  • more

Brexit: As of exit day (11 pm on 31 January 2020) the UK is no longer an EU Member State. However, in accordance with the Withdrawal Agreement, the UK has entered an implementation period, during which it continues to be subject to EU law including the General Data Protection Regulation, Regulation (EU) 2016/679. For further guidance on that period, its duration and the data protection laws that are anticipated to apply after the end of it, see Practice Note: Brexit—implications for data protection.

Introduction

It is important that personal injury practitioners are fully aware of all potential medical issues relating to the claim. The medical records should be obtained so that the appointed medical expert can review all the available evidence in relation to the medical injury when preparing his or her medical report. The medical records will assist the expert to confirm the diagnosis of the injury sustained in the accident, detail the treatment received and any noted recovery. The medical expert will be able to take note and consider any relevant pre-accident medical history and the records will assist the expert in forming his or her opinion and prognosis when preparing the report.

What is in the medical records?

The medical records consist of notes, letters, charts, x-rays, results of tests and correspondence regarding any treatment