Health records play an important role in modern healthcare. They have two main functions, which are described as either primary or secondary.
Primary function of health records
The primary function of healthcare records is to record important clinical information, which may need to be accessed by the healthcare professionals involved in your care.
Information contained in health records includes:
- the treatments you have received,
- whether you have any allergies,
- whether you're currently taking medication,
- whether you have previously had any adverse reactions to certain medications,
- whether you have any chronic (long-lasting) health conditions, such as diabetes or asthma,
- the results of any health tests you have had, such as blood pressure tests,
- any lifestyle information that may be clinically relevant, such as whether you smoke, and
- personal information, such as your age and address.
Secondary function of health records
Health records can be used to improve public health and the services provided by the NHS, such as treatments for cancer or diabetes. Health records can also be used:
- to determine how well a particular hospital or specialist unit is performing,
- to track the spread of, or risk factors for, a particular disease (epidemiology), and
- in clinical research, to determine whether certain treatments are more effective than others.
When health records are used in this way, your personal details are not given to the people who are carrying out the research. Only the relevant clinical data is given, for example the number of people who were admitted to hospital every year due to a heart attack.
Types of health record
Health records take many forms and can be on paper or electronic. Different types of health record include:
- consultation notes, which your GP takes during an appointment,
- hospital admission records, including the reason you were admitted to hospital,
- the treatment you will receive and any other relevant clinical and personal information,
- hospital discharge records, which will include the results of treatment and whether any follow-up appointments or care are required,
- test results,
- photographs, and
- image slides, such as those produced by a magnetic resonance imaging (MRI) or computerised tomography (CT) scanner.
There are strict laws and regulations to ensure that your health records are kept confidential and can only be accessed by health professionals directly involved in your care.
There are a number of different laws that relate to health records. The two most important laws are:
- Data Protection Act (1998), and
- Human Rights Act (1998).
Under the terms of the Data Protection Act (1998), organisations such as the NHS must ensure that any personal information it gathers in the course of its work is:
- only used for the stated purpose of gathering the information (which in this case would be to ensure that you receive a good standard of healthcare), and
- kept secure.
It is a criminal offence to breach the Data Protection Act (1998) and doing so can result in imprisonment.
The Human Rights Act (1998) also states that everyone has the right to have their private life respected. This includes the right to keep your health records confidential.
The NHS is currently making some important changes to how it will store and use health records over the next few years. See the Service description section for more information.