- What are my maternity records?
- How can I obtain my records?
- How long will it take?
- Can I be refused access to my records?
- Is there a fee?
- Can I photograph my records before I am discharged?
- Can I amend my records?
- How long are records retained?
- How can I interpret my records?
What are my maternity records?
If you receive NHS maternity care in the UK you will receive a set of maternity records, often called your handheld records, at your booking appointment, which you keep with you throughout your pregnancy and birth.
Midwives and doctors make a note of all the maternity care they provide in the records, including test and scan results. After your baby’s birth and discharge from hospital, these records are retained by the hospital.
Many hospitals also use electronic systems for making notes during labour. Some hospitals may print out these records and add them to the handheld record.
If you have given birth at home under NHS care, the records will be taken by the midwife who has attended you and she will give them to the local hospital.
If you have used private maternity care, your care provider will retain a copy of your notes.
Healthcare records are also made about your baby, once s/he is born.
How can I obtain my records?
You have a right under the Data Protection Act 1998 and under Article 8 of the European Convention on Human Rights to access your own health records.
You can ask your GP, midwife, doctor or health visitor informally, at any time, whether they can obtain your records for you to view in person at the GP’s surgery or hospital.
You can also submit a formal written request, known as a ‘subject access request’, to view your notes under the Data Protection Act 1998. This is usually sent to the NHS Trust’s medical records manager or the GP surgery’s practice manager. The address will be available on the website of the relevant NHS Trust or Health Board.
You and your partner, if s/he has parental responsibility for your child, have a right of access to your child’s medical records.
The Information Commissioner provides standard letters that you can use to make a request.
How long will it take?
Subject access requests must be processed within 40 days. The NHS is committed to providing healthcare records within 21 days.
If you are considering making a complaint, it may be helpful to write down your own recollection of events while you wait to receive your records.
Can I be refused access to my records?
Access can be refused on two grounds: if the person holding the records believes that providing the information may cause serious harm to the patient’s physical or mental health; or if access would disclose information relating to a third-party (non-healthcare professional), unless the third-party consents or it is reasonable to disclose the information.
It is very unlikely that either of these grounds would apply to maternity records.
If you encounter any difficulties obtaining your notes, you can make a complaint to the Information Commissioner’s Office.
Is there a fee?
A fee (up to a maximum of £50) is usually payable if you require copies of your notes. A fee of £10 is payable for copies of notes held entirely on a computer. A fee of £10 may also be charged for viewing the notes. If the notes have been added to in the last 40 days, viewing should be free. Details of the fees are available on the NHS Choices website.
The fee is discretionary and intended to cover administrative costs, such as photocopying.
You have a right to access medical information that is held about you, so if you cannot afford to pay for your records and you can show that you are on a low income, the hospital ought to waive the fee.
Can I photograph my records before I am discharged?
Individuals are sometimes informed that they are not allowed to photograph their notes before they leave the hospital and that they must make a formal request under the Data Protection Act. Your maternity records are officially owned by the NHS Trust and they are entitled to control whether copies are made. However, you can ask at anytime during your care to view, and photograph, your records informally without making a subject access request.
Can I amend my records?
The Data Protection Act requires that all records are factually accurate and up-to-date.
If you discover an inaccuracy in your records, you can request an appointment with the health professional who made the record and ask for it to be amended. If they do not accept that the record is inaccurate, you should be permitted to include a written statement in the record stating that you disagree with it.
How long are records retained?
Your maternity records and your child’s records must be retained for 25 years after the birth of your child.
How can I interpret my records?
Once you have the records, you may want to go through them with a health professional in order to understand any jargon or technical references. Your local hospital may run a Birth Afterthoughts service, which could help you understand your notes, or you can ask your GP or health visitor for assistance.
Disclaimer: Our factsheets provide information about the law in the UK. The information is correct at the time of writing (May 2017). The law in this area may be subject to change. Birthrights cannot be held responsible if changes to the law outdate this publication. Birthrights accepts no responsibility for loss which may arise from reliance on information contained in this factsheet.