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GPs must explain complex words for patients' health record requests

GPs should explain complex words and provide definitions when complying with patients’ requests to see their health records, the Information Commissioner’s Office has said.

Its ten-step guidance document for public bodies states that members of the public can be charged up to £50 for some Subject Access Requests, which include health records, and public bodies have a duty to make sure the information is intelligible.

It also revealed that the health care sector was responsible for around 600 of the 6,000 complaints over SARs in 2012/13, but complaints about the sector decreased from the previous year.

The requests are a legal route used by individuals to receive information that an organisation such as a GP practice holds about them, where their information is being held, whether it is being processed, and if so why.

The ICO advised GPs to explain complex words used in health records and provide definitions of terms that a lay person might find difficult to understand. Acronyms and test results should also be made intelligble, it said.

The ICO’s guidance said: ‘If the information includes complex terms or codes, then make sure you explain them.’

An ICO spokesperson clarified that acronymns, codes test results should be put into an ‘intelligible’ form for patients: ‘When an SAR is requested it has to be in an intelligible form. If it is full of acronyms and language people can’t understand, you need to turn it into an intelligible form for them. If there are codes in it or test results are unintelligible, you need to make them intelligible’.

Practices should also make sure they know whether the person asking for the information wants it for themselves or for others, the guidance said. Practices should find out early on what information they will need to complete the request for information, it added.

If the record contains information regarding another person, then the GPs should decide whether it is appropriate to provide the information, if everyone named in the request has not given their permission, said the guidance.

Access to the information could also be denied if the record holds information about the mental or physical health of an individual, which could cause harm to them or another person - but only if the individual does not know about the information held, it added.

The guidance reminded GPs that they should also deny access to the information to family members or legal guardian if the individual expresses this should be the case.

While ICO guidance said GPs have 40 days to comply, the DH suggests GP should aim to reply within 21 days.

Practices can charge £10 for a wholly electronic record, £50 if the record is wholly or partially non-electronic in form, and cannot issue a charge if they are non-electronic, and have been added to or formed 40 days before the request.

Readers' comments (4)

  • ... the world has gone mad ....

    I will have to cancel one surgery of patients per week to go through notes in this detail to ammend the language for these requests ....

    That will be a good use of my time!

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  • The world has indeed gone mad.
    This is how a politically motivated out of control bureaucracy destroys a profession and a national treasure (the NHS).
    All we can do is to keep calm, ignore insane directives and carry on caring for our patients.
    Then wait to be punished for doing so.

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  • a friend of my told me patient received copy of letter from cardiology " this lady had ectopic"
    she brought letter to him she had all children born normally and never had ectopic.
    tell hospital doctors not to use medical terms when copies sent to patients.

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  • From now the history will be recorded as spoken by the patient...."I think I've torn my banjo string"....may save some time at a later date should I have written the word frenulum!

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