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Summary Care Record

There is a new Central NHS Computer System called the Summary Care Record (SCR). It is an electronic record which contains information about the medicines you take, allergies you suffer from and any bad reactions to medicines you have had.

 

Why do I need a Summary Care Record?

Storing information in one place makes it easier for healthcare staff to treat you in an emergency, or when your GP practice is closed.

This information could make a difference to how a doctor decides to care for you, for example which medicines they choose to prescribe for you.

Who can see it?

Only healthcare staff involved in your care can see your Summary Care Record. 

 

How do I know if I have one?

Over half of the population of England now have a Summary Care Record. You can find out whether Summary Care Records have come to your area by looking at our interactive map or by asking your GP

Do I have to have one?

No, it is not compulsory. If you choose to opt out of the scheme, then you will need to complete a form and bring it along to the surgery. You can use the form at the foot of this page.

More Information

For further information visit the NHS Care records website

 

Sharing Your Records To Support Your Care

 

Sharing your records to support your care

 

What is changing?

By the end of the autumn of 2015 most GP practices in Portsmouth, and most of the community and mental health services in the city, will be using the same computer system to record and to store medical records.

 

The idea is to improve the care patients receive. Until now each NHS organisation and GP practice has held its own record for each person they treat – this information is not automatically shared, and so the person treating you might not be able to see the most up to date information about you.

 

From now, the organisations using the shared IT system will have access to a single patient record – staff treating you will be able to see your whole medical history, not just part of it.

 Which services will be affected?

Some Portsmouth GPs are already using the IT system, and by the end of the autumn 2015 most practices will have transferred. By the end of October 2015 most community and mental health services in the city will have transferred as well.

 

In Portsmouth, the community and mental health services in question are provided by Solent NHS Trust – their services include health visiting, community nursing, physiotherapy, and talking therapy services. A full list is available on their website: http://www.solent.nhs.uk/services

Four GP practices are not planning a transfer at the moment but may do so in the future.   These are Northern Road, Queens Road, Craneswater Group Practice and North Harbour. Patients registered at these practices are not affected at this time.

 

 What will this mean for patients?

Until now, each NHS organisation has kept its own records for every patient using their services. That has meant that GPs cannot immediately access community nursing notes, for example, and community nurses cannot see their patient’s GP records.

 

In future, when two services are both using the shared IT system they will use the same single patient record for their notes on your care. It will be possible for records of your care to be shared between services.

 

This will mean that:

  • The professionals treating you will be fully informed about your medical history, including medication and allergies.
  • The information they see will be up to date - there will be no delays caused by waiting for information to be passed on by phone, fax or post.
  • You will not need to repeat the same information to different people time and again
  • You will avoid unnecessary appointments or tests.

 

Your consent is the key to information sharing – it is your decision.

 

The process for sharing your record will be set up automatically, but you must still be asked for your consent before the person treating you can open your notes from another service. You will only be asked once when you first visit the service. If you want to restrict all or part of your records from being viewable outside of the service, you can request this.

 What do I do if I am content for my record to be shared?

If you are content that your full record can be seen by those involved in your care, you do not need to do anything. To ‘double-check’ that you agree, you will also be asked – in person – whether you consent to your information being shared before any service can access your record for the first time.

 What if I don't want my record to be shared?

 

I do not want to share any part of my record. If you do not wish any other health organisation to be able to see your records, you can inform your GP. All patients who are registered at practices which use the shared IT system have been sent a form enabling them to do this.

 

However it is important to note that, if you choose this option, your GP record will continue to be shared within the GP Practice, as it is now, and your Solent NHS Trust record will still continue to be shared within Solent NHS Trust, as it is now.

 

I do not want certain parts of record shared. If you do not wish certain parts of your clinical record to be shared, or to be restricted to certain professionals teams, then you can request this. The professional treating will then take the appropriate action to ensure that your record is restricted.

 If I consent to sharing my records, who will be able to see my information?

If you give your consent, only the professionals involved in your care are permitted to access your records, and they can only view the information relevant to the treatment they are giving you.

 

Non-clinical support staff working in a service will have access to limited information, just to enable them perform their role, e.g. booking your appointments.

 

Everyone working with patient information is bound by data protection laws. All our services have a duty of confidentiality to only access information where it is needed to provide treatment or to protect your safety. The penalties for breaking these rules are severe and organisations regularly audit access requests to identify any inappropriate use.    

Can my record be shared without my consent?

Your record will not be shared without your consent – except in two very specific circumstances.

 

Firstly, your record could be shared if there was a medical emergency – for example, you are unconscious – and secondly if there was a legal requirement for information to be shared.

What if a person is not capable of making their own, informed decisions?

If a person has been assessed – under the terms of the Mental Capacity Act 2005 - as not being able to make decisions about their care and treatment, then the existing procedures for making a decision on their behalf will be used. You can read more about where this might apply on the NHS Choices website by searching 'mental capacity': http://www.nhs.uk/Conditions/social-care-and-support-guide/Pages/mental-capacity.aspx

Will my complete patient record be shared?

Yes – if that is your choice. Records on the existing computer systems will be transferred to become part of your single health record, but you have the option to make some, or all, of your record unavailable for sharing if you wish to do so.

What about treatment in hospital?

At the moment none of the services at Queen Alexandra Hospital are using the IT system which will be shared by GPs and community and mental health services, so their records will be kept on their current system. Hospital staff, GPs and community teams will continue to inform each other as appropriate in the same way as they do now through letters, secure fax and telephone calls, as required.

What about social care records?

At the moment Adult and Children's Social Care do not use the IT system which will be shared by GPs and community and mental health teams, and so NHS social care professionals will continue to share information, as appropriate, in exactly the same way as they do now.

 

The exception to this are any social care workers who are already involved in your treatment as part of a joined up health and care team, and who therefore may also access your care plans, with your permission.

What about treatment in another part of the country?

If you are away from home and need care from an NHS service which uses the same IT system as GPs and community teams in Portsmouth, then it is possible for the person treating you to see your patient record. If this does happen, your GP will be automatically notified.  

I have also heard about Summary Care Record and Hampshire Health Record. What are the differences?

The Summary Care Record (SCR) is a national initiative to ensure NHS services can access important information about any medicines you are taking, allergies you suffer from, and whether you have reacted badly to any medicines. It does not include information on diagnosis, operations, or procedures.

 

The Hampshire Health Record (HHR) is an electronic summary record for people living in Hampshire, Portsmouth and Southampton. GP Surgeries, hospitals, social care and community care teams store information about you on separate computer systems, and the Hampshire Health Record brings together a summary of all of that information in one place so that – with your consent – professionals can view it to deliver better care to you. This record is only available to organisations in Hampshire. For more information visit: www.hantshealthrecord.nhs.uk.

 

These are different from the shared patient record held by your GP and community teams, which allows the person treating you to see your full clinical record (with your consent).

What are your future plans to develop clinical information sharing?

In the longer term the ambition is that anyone involved in providing care to you – including hospital staff as well, for example, and perhaps social care teams – will be able to access the data they need, ensuring they can provide the best support they can.

Is there a risk if I do not share my record?

It is your choice if you do not want all, or part, of your record to be shared. If you choose not to share your information it may result in the delivery of your care being less efficient as health professionals will not see your full medical history.

What if I have already stated I do not wish my information to be shared?

If you have previously advised Solent NHS Trust or your GP that you do not give, or have withdrawn, your consent to share all or part of your clinical record, this decision will be upheld, and will not be changed.

Who can I contact for further information?

Speak with one of the people providing you with care outside hospital – either your GP, or your NHS community or mental health worker.



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