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Overview:
Obtaining your Medical
Records
1 : Obtaining your records / 2 : Areas within medicine /
3 : Healthcare personnel /

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Medical Claims Online
Specialists in medical negligence

1: Obtaining Your
Records “The Data Protection Act
Obtaining your medical records 1998 provides access to
from your GP or Hospital should medical records. A copy of the
be relatively simple. A request for requested records must be
medical records should be done supplied within 40 days.”
under the Data Protection Act
1998.

You should write (although it can be done orally) any refusal. You also have the right to request to
to the holder of your records to request them. You view your records at any time. A fee to do so may
may limit your request to certain dates / specialities be payable.
or you can request them in their entirety.
Requesting records of a person that has died is
The holder of your records will then have a period slightly different, in that the
of 40 days to provide you with a copy of the request is made under the Access to Health
requested records. A fee of up to £50.00 will be Records Act. The fee for copying records of a
payable. GPs and Hospitals receive a large number deceased person is not limited to £50.00.
of requests for records. It is not always possible for Only a person legally entitled (such as the
them to provide them within the 40 day time administrator of the deceased’s estate) is able to
limit. They should, however, inform you of any request the records.
delay.
Records held by a GP will normally be sent to the
Further, it is often necessary for the records to be PCT on a person’s death. Your request will be
checked for references to third parties; these must forwarded by the GP to the PCT. The 40 day time
be redacted prior to release to you as the Data limit still applies.
Protection Act only relates to information about
you. Unacceptable delays, or refusals, can be dealt
with by way of an application to the Court. This is
used as a last resort by Lawyers to ensure the
request is dealt with and to challenge

Obtaining Medical Records

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2: Areas Within
Medicine “Medical care is divided
into three groups
Primary Care
instead of Primary Care,
Primary Care is thefront line of healthcare and Secondary Care and
includes, Pharmacy, General Practice, Accident
and Emergency and Out of Hours Services. Tertiary Care”

SecondaryCare
Secondary care includes specialties to which a GP
would refer. So, Neurologists, for example, would
be involved in secondary care.
However, Emergency medicine also covers the
Ambulance service. It does not cover intensive
care. The doctors working within an intensive care
unit are known as “Intensivists”.

Tertiary Care
Tertiary care involves more specialised medicine
and surgery. A spinal injury centre or rehabilitation
unit would fall under tertiary care services. There
are many different areas within medicine but these
can be split between: Medical, allied
(or paramedical) and Surgical specialities.
Medical Specialities
Emergency Medicine
As the name suggests, Emergency Medicine is the
study and treatment of acute conditions
Emergency medicine is therefore practised within
the A&E department of a hospital.
Obtaining Medical Records
Haematology:
Is concerned with the study of the blood, the
organs that produce blood and diseases affecting
the blood.
Oncology:
This is the study and treatment of cancer.
Oncologists will diagnose and treat many forms of
cancer and will often work within specialist tertiary
care centers (an example being The Christie
Hospital).
Urology:
Perhaps technically a surgical speciality, Urology
involves the study of the male urinary system
and the treatment of its associated diseases.
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2: Areas Within
Medicine Continued
Neurology:
Neurology is the studyand treatment of diseases
of the nervous system. Neurologists treat a
range of conditions and are heavily involved
with brain injured patients. Neurologists can be
based in a secondary or tertiary care setting.
Neurologists will be involved in the rehabilitation of
a brain injured patient, often within a Rehabilitation
Centre.
Cardiology:
This is the study and treatment of heart conditions.
Cardiologists are therefore involved in the
detection, treatment and management of diseases
of the heart. A Cardio-Thoracic Surgeon performs
surgery on the heart.
Ophthalmology:
This is the treatment of eye conditions.

Radiology:
Gastroenterology:
Radiologists consider medical imaging in order to
Gastroenterology is concerned with diseases of
identify diseases / injuries. Radiology has become
the digestive system: the stomach, Oesophagus
more specialised over the years with the creation
etc.
of Neuroradiologists and Radiologists
that will only deal with a particular area of the
body. Radiologists do not perform the imaging
Paediatrics:
The branch of medicine dealing with the care of
themselves (that is, they do not take x-rays etc)
young people up to the age of 18. Other areas of
as this is done by a non-medically qualified
medicine will also have clinicians who specialise in
technician. Radiologists must have extensive
Paediatrics. There will, therefore, be Paediatric
knowledge of the human anatomy.
Neurologists and Paediatric Radiologists etc.

Obstetrics and Gynaecology:

Gynaecology is the treatment of Gynecological
(women’s) conditions and Obstetrics is the
management of pregnancy including labour.

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2: Areas Within
Medicine Continued
Neonatology: Psychiatry:
Technically a subspecialty of Paediatric Psychiatry is the study, and treatment, of diseases
Neonatology involves the care of the newborn of the mind.
infant, in particular the ill newborn. Neonatologists
would usually work within the Neonatal Intensive
Dermatology:
Care Unit and are often Neonatal Intensivists. That
Concerns the treatment of conditions affecting the
is, they care for severely ill newborns and are often
skin. Combines medicine and surgery.
tasked with the difficult decision as to when to
withdraw lifesustaining treatment.
General Practice:
General Practice is a primary care speciality.
Anaesthesiology:
It is the study of ‘family medicine’. General
This is the study of the effects of anaesthetics
Practitioners are employed by the local Primary
on the body. Anaesthetists are involved in every
Care Trust rather than an NHS Trust. GP practices
operation requiring general anaesthetic and also in
are run on similar lines to a Law firm, with
the management of pain. Pain Management clinics
Partners and salaried staff.
will be conducted by Anaesthetists.

Endocrinology:
Endocrinology is a branch of medicine dealing
with disorders of the Endocrine system.
Endocrinologists therefore deal with diseases
affecting hormone production. A disorder
affecting a gland would be dealt with by an
Endocrinologist, for example damage to the
pituitary gland.
Rheumatology:
Is concerned with treatment of diseases affecting
the rheumatic system. That is, joints soft tissues
etc. A Rheumatologist would be involved in the
treatment of arthritis and Chronic Pain Syndrome.

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2: Areas Within
Medicine Continued
Podiatry: Surgical Specialities
Is concerned with the study, diagnosis and
treatment of disorders affecting the foot and
Orthopaedics:
Orthopaedics is the study, diagnosis and
ankle.
treatment of musculoskeletal conditions.
Treatment may be surgical or nonsurgical.
Para- Medical Specialities
Physiotherapy: Cardio-thoracic:
Physiotherapy is concerned with providing services Cardio-thoracic surgery involves surgical treatment
to individuals in order to develop, maintain and of conditions affecting the heart and lungs.
restore maximum movement and functional ability,
often following an accident.
General Surgery:
The term General Surgery is a misnomer; it
is actually concerned with the treatment of
Occupational Therapy (OT):
conditions affecting the organs of the torso
Occupational Therapists assess and assist patients
For example, General Surgeons will deal with
to return to participation in normal life and
conditions ofthe gall bladder, bile duct, intestines
activities.
and stomach etc.

Colorectal:
Orthotics:
This speciality evolved from General Surgery.
Is concerned with the design and fitting of devices
Colorectal Surgeons treat conditions affecting
that correct musculoskeletal deformities and
the lower digestive tract: the colon, anus and
abnormalities of the body.
rectum.

Plastic Surgery:
Plastic Surgery is a surgical speciality concerned
with the restoration of form and function within the
body. There are two distinct areas: modification
and reconstruction.
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2: Areas Within
Medicine Continued
ENT:
ENT stands for Ears, Nose and Throat. ENT
surgeons identify and treat abnormalities within
these three areas. This includes the treatment of
head and neck cancers.

Neurosurgery:
Deals with the treatment of conditions affecting
the Central Nervous System, whichincludes the
brain and spine. It also involves the treatment of
diseases affecting the Peripheral Nervous System,
which includes nerves throughout the body.

Next / 3: Healthcare Personnel

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Specialists in medical negligence

3: Healthcare
Personnel
Medicine involves numerous professionals
working together, some medically
qualified and others not.Below is a list of
the various personnel that you will come
across when considering your medical records.
Doctors
Doctors are medically qualified and must complete a medical degree,
foundation training and speciality training. There are various grades of
doctors.

Foundation Year 1: In the medical records this will be abbreviated as FY1.

You may also see the old abbreviation, PRHO. These doctorsare in their first
year of the Foundation Program and are therefore in their first year out of
their medical degree. They will be very inexperienced and will be heavily
supervised.

Foundation Year 2: Will be abbreviated as FY2 or SHO. These doctors are in

their second year of the Foundation Program.

Speciality Registrar: Abbreviated as SpR [name of speciality]. For

example, you may see in the records SpR Neurology. These doctors are in
their speciality training and have therefore completed the Foundation
Program.

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3: Healthcare
Personnel Continued
Doctors section 2
GP Registrar: These doctors have commenced the GP training route rather
than the hospital route. They are effectively Specialist Registrars but have
chosen to practice general medicine.

General Practitioner: An autonomous doctor specialising in general

practice. They will have completed the necessary training. They are the
equivalent of a Hospital Consultant.

Consultant: Consultants are autonomous specialists in their

chosen field. They will have completed their required training.

Next / Nurses

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Specialists in medical negligence

3: Healthcare
Personnel Continued
Nurses
Nurses are at the forefront of patient care. Nursing has become much more
specialised over the years and there are now a number of different types of
Nurses:

Practice Nurses: Practice Nurses specialise in general practice and are

therefore based within a GP practice. Often, Practice Nurses will specialise
in a specific area of general practice, for example Diabetes, Coronary care
and asthma. These Nurses will be responsible for all patients within the
practice suffering from, for example, diabetes. They will be responsible for
the monitoring and treatment of the conditions.

Nurse Practitioners: Nurse Practitioners are Nurses who have undergone

the practitioner training (post graduate level training) enabling them to be
more involved in a patient’s care. They will be involved in the diagnosis and
treatment of certain conditions. A patient would usually be assessed
by a Nurse Practitioner on initial attendance at Accident and Emergency.

Nurse Consultants: Nurse Consultants are very experienced Nurses who

specialise in a particular area of medicine within a hospital.

Specialist Nurses: Because nursing (and medicine in general) has become

more specialised over the years there are now Nurses that include: SCBU
Nurses, Psychiatric Nurses, and Nurses specialising in Urological medicine.
They are nurses that have built up many years of experience within the field
and are often Nurse Practitioners, but not necessarily so.

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Specialists in medical negligence

3: Healthcare
Personnel Continued
Other Personnel
Physiotherapists: Physiotherapists work either within a hospital setting or
within the community usually based at a GP practice or in private consulting
rooms. Their aim is to develop, maintain and restore maximum movement
and functional ability, often following an accident. Physiotherapists will be
heavily involved in the rehabilitation of patients with brain, spinal and severe
orthopaedic injuries.

Psychologists: Psychologists are trained in the recognition of psychological

symptoms, in quantifying these symptoms and in attempting to treat them
using various non drug techniques. Psychologists are not medically trained
but will have had a graduate training in psychology followed by professionally
supervised practice.

Healthcare Assistants: Healthcare assistants can work within hospital or

community settings under the guidance of a qualified healthcare professional.
The role can be very varied depending upon the area in which the person is
employed. Working alongside nurses, for example, they may sometimes be
known as nursing auxiliaries or auxiliary nurses. Healthcare assistants also
work along side qualified midwives in maternity services. The types of duties
include the following:
• washing and dressing • feeding
• helping people to mobilise • toileting
• bed making • generally assisting with patients’ overall comfort
• monitoring patients’ conditions by taking temperatures, pulse, respiration
and weight (Obs).

Occupational Therapists: Occupational Therapists assess and assist patients

to return to participation in normal life and activities.

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Obtaining Medical Records