Medical record request nhs hospital

[Sarah2025]

If I request my medical records from a c-section what information can I expect to be included? Does anyone have a format template of how it should look and what information should be included about all medical professionals present or does each nhs hospital have their own individual templates?

Is it because you are unhappy with your treatment? If so, contacting PALS might be a good first step.

You’ll need to make a Subject Access Request.

You’ll probably need to provide your name, address, date of birth, NHS number (if known), and details of the specific records requested (e.g., specific dates or full history), but having a look at the website for the relevant Trust may give you more information.

I have my records but know from other mentions of people talking about their medical records from procedures that all the relevant info is not included. For example doctors are writing just their surnames like Dr Brown and no GMC numbers for any doctor just the surgeon. It's all handwritten and no printed version of who was present during the c-section.

There should be an op note that has the basics of the surgery, but it won’t list all the scrubs nurses and techs etc who were present.

To add to that, I’ve only ever seen printed op notes even in trusts who still use paper notes so it sounds like something may be missing.

For the handwritten notes before / after surgery, the doctors should be signing everything with full name, role, and GMC number but frequently don’t bother.

I used to work in Medical Records. Years ago now, but I had to redact any full names of professionals.

Not all Trusts make electronic (typed) notes.

What was the justification for the redaction?

That’s really interesting. I didn’t realise the professionals names were redacted. That seems at odds with GMC best practice / NMC code of conduct etc about always introducing yourself fully and being willing to give your GMC number if asked. Surely patients have the right to know who they saw?

I had my birth notes ten years after the event as part of a debrief/therapy. There are very obvious chunks of information missing. There were however a couple of photocopies of a blue paper towel with notes on by the midwife 🤷‍♀️

In my job I see a lot of SARs.

I have never seen an HCP name redacted and am struggling to think of why this would be and on what legal grounds.

I was working under the old Data Protection Act, so things may be different now. Dr Smith was left in. Dr Catherine Smith would have the first name lopped out.

There was some weird logic that I didn’t fully understand! It was one of those jobs where you just followed rules.

Most of these requests were actually to legal firms rather to the patient. Patients were (and still are) encouraged to review their record(s) with a professional so everything can be explained. In this case things weren’t redacted.

All our notes are handwritten for c sections apart from ELCS. It is only a requirement for the operating surgeon to write their GMC number on the operation notes, not for every doctor present although our anaesthetists tend to on their anaesthetic chart which will be a separate document to the operation notes.

If you are trying to specifically identify someone then the trust will have an online system such as galaxy where every person in theatre will have their name logged, but how you would get access to that name would depend entirely on context as to why you need it.