Oxford Health

Health Records

We need information about you to help us provide your healthcare and services.  We also use your information for some healthcare related purposes like research and audit.

Information about you is used by authorised staff in the Trust.  This is an important aspect of the care you receive and the information is kept in manual and electronic record systems.

We keep your information confidential and secure.

The Trust is required to use your information in accordance with the law and use it for healthcare or healthcare related purposes only.  We will only share your information beyond these purposes with your consent or if we are required to by other law (Child Protection, for example).

The Trust has produced a leaflet called ‘Your Rights and Your Health Record’, which is available from your Care Team, or can be accessed via the link at the bottom of this page.  This leaflet gives a fuller explanation of how we use your information.

You can apply for access to your records but this must be in writing.  The application form is available from your Care Team or from the Health Records Department.

To obtain an application form from the Health Record Department, please contact us on 01865 325 660, email subject.access@oxfordhealth.nhs.uk or write to us at:

Oxford Health NHS Foundation Trust
Health Records Department
Littlemore Mental Health Centre
White Building
Sandford Road
Littlemore
Oxford OX4 4XN

Application for access to health records

To access health records, please fill in the health records application form and send the form to the Health Records Department at the above address.

Frequently asked questions

What is my health record?

Your health record contains information provided to us by you or other people involved in your care and treatment.

When you are first seen by the Trust, a record will be started and this will be added to by staff as your care or treatment continues.  This information will be stored electronically. It is kept to ensure that you receive the best possible care, both now and in the future.

How does the Trust keep my information secure and confidential?

We take security and confidentiality very seriously.  Staff are required to abide by strict codes of conduct and participate in regular training. Everyone in the NHS has a legal duty to keep information about you confidential.  This means that we only share information with those who have a genuine need to know but may include people who provide care to you from organisations other than the NHS.  They too have a legal duty to keep information confidential.

Can anybody else see my record?

Yes but the person applying must have written authorisation from you.  If you become incapable of giving authorisation, the person appointed by a Court to manage your affairs can give it.

Are there charges to see my record?

There is no charge to look at your paper record if these have been added to within 40 days prior to the receipt of your written request.  If your request were outside that period, a charge up to a maximum of £50 may be made.

If you wish to be given copies of your records, a charge up to a maximum of £50 may be made.

Please note that you will need to pay any charges before you can see your records.

How is my information used?

The main purpose is to provide you with the appropriate healthcare and treatment.  People who may see the information include:

• Administrative Staff supporting the Healthcare Team, e.g. Medical Students
• your Family Doctor

If you agree, your relatives, friends and carers will be kept up to date with the progress of your treatment.

Your information will also be used for  other NHS purposes and if appropriate, passed on to other partner organisations so we can all work together for your benefit.  The sharing of information is strictly controlled and wherever possible we will remove details that identify you.

Uses of your information will include:

• teaching and training healthcare staff
• helping staff to review the care they give to make sure it is of the highest standard
• reviewing and planning services to meet the needs of patients.  This includes sending information to Health Authorities and the Department of Health
• helping with research into better methods of healthcare.  The Local Research Ethics Committee must approve research projects.  In certain circumstances we will ask for your permission to use information about you

There may be exceptional circumstances when staff have a duty to breach confidentiality, for example, where there is a child protection issue or a risk of death.

In some situations we have a legal duty to report information to the appropriate authorities, for example:

• reporting of certain infectious diseases that might seriously affect the health of other people, e.g. meningitis or measles, NOT HIV or AIDS
• where a formal court order has been issued

How can I see the information the Trust holds about me?

The Data Protection Act 1998 gives patients the right of access to their own records, held either on computer or on paper.

• If you are receiving treatment you may arrange to discuss your records informally with your Doctor or other Healthcare Professionals.  Otherwise, you can write to the Health Records Manager (contact details above)
• When we receive your written request, you will be sent a form which asks for further details and proof of identity
• We are then required to give you access to your records within 21 days of receiving your completed form
• We have a duty to ensure you understand any medical or technical terms in your record.  You may wish to make an appointment to discuss anything you do not understand.
• If you think there is a mistake in your records, you should write and tell us so it can be noted.

In exceptional cases, information from your medical record may be withheld:

• If your doctor believes it is likely to cause serious harm to your mental or physical health.  If you think information is being withheld you may write to us.
• If you are asking to see the records of a service user who has died, under the Access to Health records Act 1990, you will need to prove that you are the person’s legal representative or that you have a claim resulting from the death.