Health records

Health records play an important role in modern healthcare. They have two main functions that can be described as being either: primary, or secondary.

Primary function of health records
Their primary function of health care records is to record important clinical information, which may need to be accessed by the healthcare professionals who are involved with your care.

Information included in health records include:

• the treatments that you have received,
• whether you have any allergies, 
• whether you are currently taking any 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 that you have had - for example, blood pressure tests, 
• any lifestyle information that may be clinically relevant, such as whether you are a smoker, and 
• personal information, such as your age and address.

Secondary function of health records
Health records have an important secondary function. They can be used to improve public health and the services that are 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 records
Health records can take many forms, and they can be both paper and electronic. Different types of health records include:

• consultation notes - notes that your GP takes during an appointment, 
• hospital admission records - which will include the reason that you have been admitted to hospital, the treatment that 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, 
• X-Rays, 
• photographs, and 
• image slides, such as those that are produced by a  magnetic resonance imaging (MRI), or computerised tomography (CT) scanner.

Confidentiality
There are strict laws and regulations to ensure that your health records are kept confidential, and can only be accessed by health professionals who are directly involved in your care.

There are a number of different laws that relate to health records. The two most important laws are the:

• 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 that 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, which also extends to the right of keeping your health records confidential.

Important changes
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.