Notes about the Standard and Summary Care Records

Summary Care Records (SCRs) enable healthcare professionals working in different care settings to access an electronic summary of key information from a patient’s GP record. Currently, SCRs are widely used across NHS urgent and emergency care, such as NHS 111, 999 and Accident & Emergency Departments. However, the SCR may also be used in planned care to provide up to date clinical information.

The Accessible Information Standard (‘the Standard’) requires health and care professionals to identify, record, flag, share and meet the information and communication needs of patients with a disability or sensory loss.

The Standard requires GPs and some other GP practice staff to record details of patients’ information and / or communication needs in their patient record using specific terms or ‘codes’ which are listed in GP Practices’ clinical record systems.

Recording information in a patient’s GP record is especially important, as it enables the information to be shared with other health and care professionals, including through the SCR.

Information for patients

The Summary Care Record is a copy of key information from your GP record. It provides authorised care professionals with faster, secure access to essential information about you when you need care. Healthcare staff will ask your permission when they need to look at your Summary Care Record.

If you choose to have a Summary Care Record, it will automatically contain important information about any medicines you are taking, any allergies you suffer from and any bad reactions to medicines that you have previously experienced.

You can also choose to add ‘additional information’ to your Summary Care Record. This will include significant medical history and details about immunisations, your information and / or communication needs and your personal preferences. This will only happen if both you and your GP agree to do this – and you should discuss your wishes with your GP practice.

If you have information and / or communication needs because of a disability or sensory loss, your GP should record your needs in your GP patient record. This is a requirement of the Accessible Information Standard.

If you would like other health and care professionals to be able to see that you have information and / or communication needs, and you have a Summary Care Record, then you should ask your GP to include ‘additional information’ in your Summary Care Record. This will mean that those treating you are able to see that you have information and / or communication needs, and take steps to meet those needs.

If you are a carer, and you think that the person you care for could benefit from having additional information in their Summary Care Record, then please support them to discuss this with their GP practice, or, if appropriate, contact their GP practice on their behalf.

For more information about Summary Care Records, visit the ‘health records’ section on NHS Choices website. You can also telephone the Health and Social Care Information Centre on 0300 303 5678 or speak to your GP practice.

Information for clinicians

SCCI1605 Accessible Information (‘the Accessible Information Standard’) requires healthcare professionals to identify, record, flag, share and meet the information and communication support needs of patients, service users, carers and parents with a disability or sensory loss.

For recording, flagging and sharing purposes, the Accessible Information Standard has defined four subsets, with associated data items available in SNOMED CT, Read v2 and CTV3.

In electronic systems which use SNOMED CT, Read v2 or CTV3 codes, details of patient’s information and / or communication needs must be recorded using the coded data items associated with the subsets defined by the Standard. Further information about clinical architecture / terminology is included in the Specification and in the ‘Terminology Summary’ document.

All of the data items associated with the four subsets of the Standard have been included in the Summary Care Record (SCR) ‘inclusion dataset’. This means that, if the patient’s information and / or communication needs are recorded in their GP patient record using the identified codes, and the patient has consented for ‘additional information’ in their SCR, then details of their information and / or communication needs will automatically be available to anyone viewing their SCR.

When recording individuals’ information and / or communication needs as part of the Standard, GPs and other relevant practice staff should also discuss the benefits of the individual consenting for ‘additional information’ to be included in their SCR. Patients must give their explicit consent for this information to be added. The consent is enduring, so the SCR is kept up to date in real time as the GP record is updated. The SCR is updated with additional information once the SCR consent setting in the GP system has been changed to ‘express consent for medication, allergies, adverse reactions AND additional information’. For further guidance on consent for additional information, see ‘patient consent and considerations for patients who lack capacity to consent’.

For further information about SCR visit the Health and Social Care Information Centre website where specific advice about SCR with additional information can be found. Leaflets are available to help ensure that patients are fully informed about additional information. There is no requirement to gain written consent, however, a combined information leaflet and consent form is available for GP practices that wish to use it.