This is the least discussed and most quietly useful right a patient has in this field. If something goes wrong, the difference between a complaint that can be examined and one that cannot is almost always a record, and the record is not in your possession unless you asked for it.
What a treatment record should contain
Regardless of who treated you or under what registration, a record of the encounter should exist. At a minimum it should record:
- The date, and who carried out the treatment.
- The product used, by full name, and the batch number.
- The dose or volume, and the sites treated.
- Where a prescription only medicine was used, who prescribed it and the date of assessment.
- The history taken and any relevant findings from examination.
- The information given and the consent obtained.
- Aftercare instructions and the escalation arrangements given to you.
Product and batch deserve emphasis. If a problem arises, that pair of facts is the first thing anyone competent will ask for, and it is also what would be needed for a report to the MHRA Yellow Card scheme, described in how to check a claim about a product or device.
- Open
- The Information Commissioner's Office guidance for the public
ico.org.uk - Type in
- Search the ICO site for guidance on your right of access to your personal data, and for how to make a complaint if an organisation does not respond.
- A good result looks like
- Published guidance setting out the right, the time limits, what an organisation must provide, and the route to complain if it does not.
- An ambiguous result looks like
- Third party summaries of data protection law with no source. Clinic terms that describe a charge or a process inconsistent with the published guidance.
- What it does not prove
- That the clinic will comply, or that the record contains what it should. The right is to a copy of what is held. If little was recorded, little will arrive, and that itself is informative.
- Note
- Making the request soon after treatment, when nothing is in dispute, is far easier than making it during a complaint.
Your right of access
Information about your health and your treatment is personal data, and data protection law gives you the right to obtain a copy of the personal data an organisation holds about you. Clinical notes, consent forms and clinical photographs of you fall within that.
The request does not need to be formal or use any particular words, though saying that you are making a request for a copy of your personal data makes it unambiguous. There are time limits within which organisations must respond, and the Information Commissioner's Office publishes guidance for individuals about how the right works and what to do if a request is not answered.
Wording you can send
Please provide a copy of all personal data you hold about me, including my clinical notes, the consent documents I signed, the record of products used with batch numbers, and any clinical photographs. I am making a request for access to my personal data.
Send it to the clinic and keep a copy. If you receive no response within the statutory period, or an inadequate one, you can complain to the Information Commissioner's Office, which is free.
Photographs, which are two different things
Clinical photographs taken for your record are ordinary and useful. They are the only way to compare a result with a starting point, and if you are ever in dispute about an outcome, the before image is the most valuable single document in the file.
Marketing photographs are a separate matter requiring separate, specific and optional consent. Your treatment must not be conditional on agreeing to marketing use, and consent given for marketing can be withdrawn.
Three practical points. Ask whether photographs will be taken and for what purposes. Ask for copies of your own before and after images, which is part of the same access right. And if you consented to marketing use and have changed your mind, write and withdraw it, keeping a copy.
| Clinical photographs | Marketing photographs | |
|---|---|---|
| Purpose | Your clinical record | Promotion of the business |
| Consent required | Yes, as part of the treatment record | Yes, separate, specific and optional |
| Can treatment be conditional on it | No | No |
| Can you withdraw consent | Consent to processing can be revisited | Yes, and you should write to do so |
| Can you get copies | Yes, as part of your personal data | Yes |
| Why it matters to you | The only baseline for judging a result | Your image used publicly, indefinitely |
A framework written by this publication to organise the procedure. It is not a measurement, a guideline or a regulator's classification.
Take your own photographs too
This costs nothing and is worth more than it sounds. Before treatment, photograph the area yourself in good even light, from the front and both sides, with a neutral expression and again with the relevant muscles active. Repeat in the same light and position afterwards.
Clinic photographs are taken in controlled conditions that flatter change. Your own, taken in ordinary light, are what you will actually be judging the result by, and they are yours regardless of what happens to the clinic's records.
If the clinic closes
Businesses close, and records can become difficult to obtain afterwards. There are obligations around the handling of records, but as a practical matter your position is far better if you already hold copies.
This is the strongest argument for requesting your records shortly after treatment rather than only when a problem arises. It takes one email at a moment when nothing is contested and everybody is cooperative.
How the file gets used
Every complaint route on this site works better with documents. A professional regulator considering a concern about an individual will want to know what was done, by whom and when. A consumer claim needs the contract, the quotation and evidence of what was promised. A card issuer claim needs proof of the supplier and the transaction. A Yellow Card report needs the product and batch.
None of these requires you to have anticipated a problem. It requires you to have kept the ordinary paperwork of an ordinary transaction. What to do at the moment something goes wrong is set out in what to do when something goes wrong, and it begins with the file you already have.