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What is meant by Health Record?

Wherever you visit an NHS service a record is created for you. This means medical information about you can be held in various places, including your GP practice, any hospital where you’ve had treatment, your dentist practice, and so on.

A health record (sometime referred to as medical record) should contain all the clinical information about the care you received. This is important so every health professional involved at different stages of your care has access to your medical history such as allergies, operations or tests. Based on this information, the health professional can make judgements about your care going forward. Find out more about different types of records.

Your health records should include everything to do with your care including x-rays or discharge notes. The data in your records can include:

  • treatments received or ongoing
  • information about allergies
  • your medicines
  • any reactions to medications in the past
  • any known long-term conditions, such as diabetes or asthma
  • medical test results such as blood tests, allergy tests and other screenings
  • any lifestyle information that may be clinically relevant, such smoking, alcohol or weight 
  • personal data, such as your age, name and address
  • consultation notes, which your doctor takes during an appointment
  • hospital admission records, including the reason you were admitted to hospital
  • hospital discharge records, which will include the results of treatment and whether any follow-up appointments or care are required
  • X-rays
  • photographs and image slides, such as those produced by a magnetic resonance imaging (MRI) or computerised tomography (CT) scanner

Find out how long medical records are kept for

Types of Health Record

What is a Summary Care Record?

The SCR is an electronic record of important patient information, created from GP medical records. It can be seen and used by authorised staff in other areas of the health and care system involved in the patient's direct care.

There are 2 variations of SCR records:

The SCR Core record holds important information about;

  •     current medication
  •     allergies and details of any previous bad reactions to medicines
  •     the name, address, date of birth and NHS number of the patient

SCR with additional information (SCR AI) incorporates individual coded items and associated free text and will include:

  •     Significant medical history (past and present)
  •     Reason for medication
  •     Anticipatory care information (such as information about the management of long term conditions)
  •     Communication preferences (as per the SCCI1605 national dataset - formerly ISB-1605) Including the Accessible Information Standard
  •     End of life care information (as per the SCCI1580 national dataset - formerly ISB-1580)
  •     Immunisations

The SCR is created automatically through clinical systems in GP practices and uploaded to the Spine. It will then be updated automatically. Additional information can be added, with express patient consent, by the GP.

Benefits

SCRs with additional information offer the opportunity to:

  •     Increase patient safety by providing timely access to information such as significant diagnoses
  •     Empower patients and increase satisfaction as patients can make their preferences known
  •     Empower health professionals by providing consistent, accurate, accessible information
  •     Increase efficiency and effectiveness through more integrated care and reduced time/effort

(source: http://systems.digital.nhs.uk/scr/additional) 

SCR records, whether core or additional, are updated in real time – therefore clinicians and health care providers have the ability to view the latest clinical information from a patient, dependant on patient consent and appropriate access levels.

You can choose to opt out of having a Summary Care Record at any time. In that case, you need to let your GP practice know by filling in an opt-out form (PDF, 245.9kb). If you are unsure if you have already opted out you should talk to the staff at your GP practice. If you change your mind again simply ask your GP to create a new Summary Care Record for you.

What is meant by an Integrated Digital Record?

On a local level some Clinical Commissioning Groups (CCGs) have started to integrate patients’ health and social care records to improve the overall care they provide in their area and to ensure more joined up care is given to patients. This is called Integrated Digital records. 

NHS Sheffield is currently in the process of moving towards an Integrated Health and Social Care Medical Record. Under a new law (Health & Social Care - Safety & Quality 2015 Act) we as practices now have a ‘Duty to share’ patient information. Patients still have the right to opt out of record sharing. If you wish to opt out of the local sharing program, please contact you practice and they can make the necessary changes to your medical record. 

For more information about this local initiative please click on the following link : 

Local Patient Record Sharing Initiative

Below is also a link to the NHS Sheffield (CCG) website which may provide more information

http://www.sheffieldccg.nhs.uk/about-us/looking-after-your-information.htm

Sharing Data from your Record Across the NHS

Health and social care records can be used to improve social care, public health and the services provided by the NHS. Your health records can also be used:

  • to determine how well a particular hospital or specialist unit is performing
  • to track the spread of, or risk factors for, a particular disease (epidemiology)
  • in clinical research, to determine whether certain treatments are more effective than others

When health records are used in this way, your personal details are not given to the people who are carrying out the research. Only the relevant clinical data is given, for example the number of people who were admitted to hospital every year due to a heart attack.

Besides the data collected by hospitals the NHS has also started to collect similar information, at a local level, from GP practices to better plan services for patients. In the future this will expand to information about care provided in communities and care homes. You can find more detailed information about data sharing in the section The care.data programme.

Confidentiality

There are strict laws and regulations to ensure your health records are kept confidential and can only be accessed by health professionals directly involved in your care. There are a number of different laws that relate to health records. The two most important laws are:

Under the terms of the Data Protection Act (1998), organisations such as the NHS must ensure that any personal information it gathers in the course of its work is:

  • only used for the stated purpose of gathering the information (which in this case would be to ensure that you receive a good standard of healthcare)
  • kept secure

It is a criminal offence to breach the Data Protection Act (1998) and doing so can result in imprisonment.

The Human Rights Act (1998) also states that everyone has the right to have their private life respected. This includes the right to keep your health records confidential.

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