A health record is any record which consists of information relating to the physical or mental health or condition of an individual made by a health professional in connection with the care of that individual.
It can be recorded in a computerised form, in a manual form or a mixture of both. Information covers expression of opinion about individuals as well as fact. Health records may include notes made during consultations, correspondence between health professionals such as referral and discharge letters, results of tests and their interpretation, X-ray films, videotapes, audiotapes, photographs, and tissue samples taken for diagnostic purposes.
They may also include internal memoranda, reports written for third parties such as insurance companies, appointment details and clinical audit data, if the patient is identifiable from these.
Please find further information below on accessing your medical record, confidentiality, the Data Protection Act, our privacy notice and data sharing.