Introduction

The NHS summary care record (SCR) is an electronic summary of key clinical information about each patient registered with the NHS in England.  It is automatically created on registration with a GP practice in England and uses information recorded in the GP clinical system. 

The GP record is known as the ‘source record’.  Information is updated every time a relevant change is recorded in the patient’s GP medical record.

The information held in a summary care record gives registered and regulated healthcare professionals, away from the patient’s usual GP practice, access to information to provide safer care, reduce the risk of prescribing errors, and improve the patient experience.

Putting the right information in the hands of doctors, nurses, and other care professionals at the right time saves lives and improves outcomes.

The SCR can be viewed in:

• general practice clinical systems (SystemOne, EMIS Web and Vision)
• the summary care record application on the Spine portal
• through the summary care record application (SCRa) which is a web-based application

What the SCR includes

There are two types of summary care record:

• core SCR
• SCR additional information (SCRai, also called enriched SCR)

SCR content is limited to information held in GP systems and contains basic information about allergies and medications and any reactions a patient may have had to medication in the past.  The SCRai may have relevant content recorded by other organisations and shared with the GP practice and can include information about significant medical history (past and present), reasons for medications, care plan information and immunisations.

The table below shows what information may be included in each version.

Information such as carers’ details, communication needs, etc, often originates outside the GP practice with input from the patient/patient’s family.  It is important for any specific support needs to be included in the clinical record and for these needs/details to be updated when changes are made.

Levels of detail

The level of detail in an SCR depends on how information is collated and coded by the registered practice.  The record can be added to with more coded data and associated free text, subject to the decisions of the patient and responsible clinician.

Data recording varies according to:

• the clinical system in use
• local data quality
• the recording practices preferences
• patient preferences

Additional information will, therefore, vary from one record to another but will follow a broadly consistent format.

It is very important that additional information in the source record is coded appropriately, maintained, and updated in a timely manner, ideally at the point of care.  Most coded data will be available in the SCRai but will only be included in core SCR if the patient consents.

Sensitive information

In all versions of the SCR, sensitive information such as fertility treatment, pregnancy terminations, gender reassignment and sexually transmitted diseases is excluded through the Royal College of General Practitioners’ (RCGP) sensitive dataset.

Patients can, however, opt to have sensitive information included. The information must be added to the record manually.  Guidance on including additional information in the SCR can be found on the NHS Digital website.

For a comprehensive SCR/SCRai there is a reliance on correct coding within the clinical record.  There may be a small number of patients with historic coding issues, such as a problem being incorrectly identified as minor/major, and instances of codes relating to the same problem not being linked.  This serves to highlight the importance of correct use of coding within GP practices.  

Summarising patient records supports this, and it remains a contractual requirement for practices to summarise patient records.  Future development will see plans to digitise paper-based medical records, to provide more informed care decisions and patient outcomes, and deliver the NHS Long Term Plan vision.

Recording medicines prescribed outside general practice

Not all medications are prescribed within a general practice.  Other care settings, such as accident and emergency departments, community pharmacies, and by other clinical professionals like paramedics and dentists, can also prescribe medication to patients, including repeat medication.

If these medications are not recorded back into the GP practice record, this could result in healthcare professionals not having enough information to make an informed clinical decision about a patient’s care and may put patients at risk of medication errors.

Recording medicines prescribed elsewhere into the GP practice record explains why medicines prescribed outside a patient’s GP practice must be recorded into their GP practice record as soon as the practice is made aware, and the implications to the SCR when this is not done.  It also explains what steps GP practices can take to ensure that this information is recorded correctly.

Where SCR is used

When patients are at their most vulnerable, giving health and care professionals access to their SCR enables them to better understand the patient’s needs and make the best decisions with and for them. 

SCR can be accessed in a wide range of settings, subject to access controls:

• acute trusts (both unscheduled and scheduled care)
• GP practices
• GP out of hours services
• NHS 111
• walk-in centres
• urgent treatment centres
• minor injury units
• mental health
• community pharmacy
• custody suites
• prisons
• hospices
• community care
• district nursing
• ambulance services
• drug and alcohol services
• smoking cessation clinics
• private healthcare
• social services
• child protection

The following settings and use cases are currently not in scope for SCR viewing and will not be approved for rollout:

• research purposes, including clinical trials
• police and other government departments
• non-clinical cosmetic service providers

Two exceptions were granted under an urgent public health need for COVID-19 clinical trials.  These were the Principle and Panoramic trials.

Note | Where the patient cannot give their permission, the clinician treating them can still access the SCR without their consent where it is deemed in the best interests of the patient.