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

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1: Obtaining Your Records
Obtaining your medical records from your GP or Hospital should be relatively simple. A request for medical records should be done under the Data Protection Act 1998.

“The Data Protection Act 1998 provides access to medical records. A copy of the requested records must be supplied within 40 days.”

any refusal. You also have the right to request to You should write (although it can be done orally) 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 request is made under the Access to Health of 40 days to provide you with a copy of the Records Act. The fee for copying records of a requested records. A fee of up to £50.00 will be 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 administrator of the deceased’s estate) is able to them to provide them within the 40 day time request the records. limit. They should, however, inform you of any delay. Further, it is often necessary for the records to be checked for references to third parties; these must be redacted prior to release to you as the Data 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

Records held by a GP will normally be sent to the PCT on a person’s death. Your request will be forwarded by the GP to the PCT. The 40 day time limit still applies.

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

into three groups instead of Primary Care, Secondary Care and 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.

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).

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.

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:
Radiologists consider medical imaging in order to identify diseases / injuries. Radiology has become more specialised over the years with the creation of Neuroradiologists and Radiologists that will only deal with a particular area of the body. Radiologists do not perform the imaging themselves (that is, they do not take x-rays etc) as this is done by a non-medically qualified technician. Radiologists must have extensive knowledge of the human anatomy.

Gastroenterology:
Gastroenterology is concerned with diseases of the digestive system: the stomach, Oesophagus etc.

Paediatrics:
The branch of medicine dealing with the care of young people up to the age of 18. Other areas of medicine will also have clinicians who specialise in Paediatrics. There will, therefore, be Paediatric 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:
Technically a subspecialty of Paediatric Neonatology involves the care of the newborn infant, in particular the ill newborn. Neonatologists would usually work within the Neonatal Intensive Care Unit and are often Neonatal Intensivists. That is, they care for severely ill newborns and are often tasked with the difficult decision as to when to withdraw lifesustaining treatment.

Psychiatry:
Psychiatry is the study, and treatment, of diseases of the mind.

Dermatology:
Concerns the treatment of conditions affecting the skin. Combines medicine and surgery.

General Practice:

General Practice is a primary care speciality. 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.

Anaesthesiology:

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:
Is concerned with the study, diagnosis and treatment of disorders affecting the foot and ankle.

Surgical Specialities
Orthopaedics:
Orthopaedics is the study, diagnosis and treatment of musculoskeletal conditions. Treatment may be surgical or nonsurgical.

Para- Medical Specialities
Physiotherapy:
Physiotherapy is concerned with providing services to individuals in order to develop, maintain and restore maximum movement and functional ability, often following an accident.

Cardio-thoracic:
Cardio-thoracic surgery involves surgical treatment of conditions affecting the heart and lungs.

General Surgery:
The term General Surgery is a misnomer; it is actually concerned with the treatment of conditions affecting the organs of the torso For example, General Surgeons will deal with conditions ofthe gall bladder, bile duct, intestines and stomach etc.

Occupational Therapy (OT):
Occupational Therapists assess and assist patients to return to participation in normal life and activities.

Orthotics:
Is concerned with the design and fitting of devices that correct musculoskeletal deformities and abnormalities of the body.

Colorectal:
This speciality evolved from General Surgery. Colorectal Surgeons treat conditions affecting the lower digestive tract: the colon, anus and 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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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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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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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.
Obtaining Medical Records

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Obtaining Medical Records