Your medical records

Your doctor and other health professionals caring for you (e.g. nurse or physiotherapist) keep records about your health and treatment so they are able to provide you with the best possible care. 

What makes up your medical record?

Information that you have given us, or provided by other people involved in your care and treatment. This information may be stored either electronically or in paper files. This will include details such as your name, address, date of birth and next of kin; visits you have made to our services; details and records about the treatment and care you need or have received; results of investigations such as laboratory tests, and other relevant information concerning your health and wellbeing.  It is important we keep this information to help us meet your healthcare needs.

How is your medical record used?

We aim to provide you with the highest quality of healthcare.  To do this, we must keep records about you, your health and the care we have provided or plan to provide you.  It will also be used to audit/assure the quality of healthcare provided.  Your records are used by the people who care and provide healthcare services to:

  • Provide a basis for all healthcare decisions made by you and healthcare professionals
  • Allow you to work with those providing your care
  • Make sure your care is safe and effective
  • Work effectively with others providing you with care and support
  • Check the quality of care (called clinical audit)
  • Provide administrative support for the delivery of health services 

Information within your record may also be used to help the NHS to:

  • Protect the health of the general public
  • Review and plan services to meet the needs of patients in the future
  • Audit NHS accounts and services
  • Prepare statistics on NHS performance
  • Help investigate any concerns or complaints you or your family have about your healthcare
  • Teach and train healthcare workers
  • Help with patient satisfaction surveys
  • Research into better methods of healthcare
  • Manage healthcare services, which encompass sharing information with the Department of Health and NHS Managers, Occupational Health Practitioners, Bodies with Statutory Investigative Powers, NHS Complaint Committees, NHS Litigation Authority and National Registries which assist with the study and monitoring of specific diseases, e.g. Cancer registries.

In these circumstances, we shall anonymise information that may identify you so that your personal details are kept private, however there may be occasions where we have a legal or professional duty to disclose that information.

In some situations, we have a legal duty to share information about you to the appropriate authorities, for example: Notification of new births; Reporting of certain infectious diseases which might seriously affect the health of other people, (e.g. Meningitis or measles, but not HIV/AIDS), education or social services, the police or by Court Order.

How do we keep your information secure and confidential?

We take security and confidentiality very seriously.  All Staff are required to abide by codes of conduct and participate in regular confidentiality training.

Everyone working for the NHS has a legal duty to keep information about you confidential. 

This means that we must share information only with those who have a genuine need to know.  This may include people who provide care to you from other healthcare organisations, voluntary sector support services and public authorities. They also have a legal duty to keep information confidential, and wherever possible we will remove details that identify you if it is not necessary to disclose them as part of your care.  There may also be occasions we need to discuss information we have about you with your partner or relatives, such as in emergency situations or intensive care where you don’t have the capacity to be able to help us plan your care. We endeavour to limit the information we share about you only that which is necessary to ensure we provide you with the right treatment and care.

NHS Digital provides a code of practice for all NHS Trusts on health records management 

Can I access my medical records?

Yes. You can apply to access your health records under the Data Protection Act 1998 (from 25 May 2018, the right of access will be governed by the General Data Protection Regulations). You will need to provide proof of identification to access your records.  Details of how to apply and the forms to use are provided here:

Application guidelines.pdf

SAR - Application-for-Access-to-Health-Records

Children (age 16 and under) can also apply to see their own medical records.  A request from a child will be considered but only where it is felt that the child can fully understand the information held.

In exceptional cases, information from your medical record may be withheld if your doctor believes it is likely to cause serious physical or mental health harm to you or someone else.

Can I access someone else’s medical records?

You can only access other people’s medical records with their written consent or if you have proof that you have a legal right of access for example a Power of Attorney or Court Order.

If you are asking to see the health records of someone who has died, under the Access to Health Records Act 1990 you will need to prove that you are the patient’s legal personal representative or that you have a claim arising from the death.

If you are asking to see your child’s records, you can only do so if you have legal parental responsibility.  Depending on the age of your child and their capacity to understand the request, we may also request confirmation that your child has understood and consented to your request.  The best interest of the child is paramount at all times and may, on occasion, mean that we limit or refuse to process your request for your child’s records.

Can I correct information held about me?

If you feel there is an error in your medical record you should write to tell us at the following address, so that the correction can be added to the record or your comments documented:

Health Records Library

Croydon Health Services NHS Trust

Croydon University Hospital

Energy Centre

530 London Road

Croydon CR7 7RY

If you have any concerns relating to the processing of your medical information, you can contact our Patient Advice and Liaison Service or alternatively, you can write to the Trust’s Caldicott Guardian, who has the responsibility to ensure the protection of patient confidentiality throughout the Trust in accordance with your legal rights:

Caldicott Guardian

Croydon Health Services NHS Trust

Medical Director’s Office

HQ, Woodcroft Wing

530 London Road

Croydon CR7 7RY

For further information or to apply for Access to Health Records, please contact:

Subject Access Team
Croydon Health Services
Woodcroft Wing, HQ Offices
530 London Road
Croydon CR7 7YE
Email: ch-tr.infogov@nhs.net

Tel: 020 8401 3000 ext. 3475 or 4049