Self-help guide
Name of Hospital or GP
Address
Dear Sir/Madam
Subject access request
Your full name and address – NHS number – hospital number, if applicable
[If requesting the records of another person, use their details]
Please supply the data about me that I am entitled to under data protection law relating to:
- My medical records which are held by you.
medical records which are 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 regarding [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.
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.
[Avma note to reader: The healthcare provider may require payment in advance of providing you with copies of the records]
Yours faithfully
[Signature]
Name