Self-help guide
Name of GP/Healthcare provider
Address
Dear Sir/Madam
Subject access request
Full name and address of person for whom you are requesting records – NHS number – hospital number, if applicable
Please supply the data about [Name of person] that I am entitled to under data protection law relating to:
- their medical records held by you.
[Avma note to reader: Include the date range you are requesting records for.
If you think you need your GP notes you should write separately and directly to your GP for copies of your GP records. The hospital may have some letters from you GP for example, referral letters, they will not have all the correspondence or the GP’s clinical entries].
- any specific records you are seeking [e.g. x-rays or real-time imaging such as ultrasound].
[Avma note to reader: Be as specific as possible about the records which are required for an initial investigation of the claim. For example, if the events leading up to the alleged negligence included an admission to hospital by way of the Accident and Emergency (A&E) department, immediately after which you underwent surgery and then developed an infection in the post-operative period, the medical records you would probably need to request include: the A&E records (including nursing and clinical notes); operating records; anaesthetic records; daily nursing records including temperature, pulse and respiration charts and fluid balance charts; any laboratory reports, X-rays etc available in relation to the infection etc.]
- any investigation reports [such as root cause analysis, serious investigation report or serious case report] which have been compiled in regard to [date and nature of the incident].
- A request for any relevant guidelines, protocols, policies in place at the time you were treated.
[Avma note to reader: you should also consider requesting any updates to those guidelines, protocols, policies especially if the allegation of negligence took place some time prior to your making a request for the medical records]
- I also request an explanation of any medical terms or abbreviations which might be unintelligible to me.
Authority to request these records:
Please find enclosed original form of authority signed by [name of person whose records you are requesting] giving me permission to request their medical records. [Avma’s explanatory note to reader: Usually a person over 18 years of age is independent and healthcare providers owe them a duty of confidentiality. It is up to you to show why you are applying for the records on behalf of someone over 18 years of age.
Example 1: If your spouse or adult child has suffered an injury but retain their mental capacity then if they are able to, you should get them to sign a form of authority confirming their consent for you to obtain copies of their medical records and correspond on their behalf – www.avma.org.uk/guides.
Example 2: If the person you are requesting records for lacks mental capacity eg, a parent with dementia or a child with a brain injury and you have a Power of attorney over their affairs, you should include a copy of the power of attorney instead of a form of authority.
Example 3: If the person you are requesting records for lacks mental capacity, but you do not have a power of attorney over their affairs then under this paragraph you should include words to the effect that “[Name of incapacitated person] is a person under an incapacity. I am seeking to give him/her help and support in relation to [say what you are helping them with] and it would be in [name of incapacitated person]’s best interests for the subject access request to be granted.”
If you are trying to obtain copies of medical records for someone over 18 who has died, please see separate template letter requesting records of a deceased person: www.avma.org.uk/guides
Details about the incident
[Avma note to reader: Under this heading you should set out brief information about the events you are concerned about to alert the healthcare provider to where an adverse outcome has been serious or has had serious consequences or may constitute a notifiable safety incident.]
Copies of medical records
If you need any more data from me, or a fee, please let me know as soon as possible. It may be helpful for you to know that data protection law requires you to respond to a request for data within one calendar month. If you are unable to process this application within that time, then please write to me and let me know when I can expect to receive copies of these records.
If you do not normally deal with these requests, please pass this letter to your Data Protection Officer, or relevant staff member.
Yours faithfully
[Signature]
Name