Wherever you visit an NHS service in England 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.
At times, this can delay information sharing which can affect decision making and slow down treatment.
To help improve the sharing of important information about you, the NHS in England is using an electronic record called the Summary Care Record (SCR) – See the section below for more information.
Since April 2015 all GPs should offer their patients online access to summary information of their GP records. To find out more about how to access medical records online or in paper see the section How to access your health records.
A health record (sometimes referred to as medical record) should contain all the clinical information about the care you received. This is important so every healthcare professional involved at different stages of your care has access to your medical history, such as allergies, operations or tests. Based on this information, healthcare professionals can make judgements about your care going forward.
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 clinically relevant lifestyle information, such as 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
- photographs and image slides, such as magnetic resonance imaging (MRI) or computerised tomography (CT) scans
Find out how long medical records are kept
Summary Care Records
If you are registered with a GP practice in England, you will have a Summary Care Record (SCR) unless you have chosen not to have one. Your SCR contains the following basic information:
- the medicines you are taking
- your allergies
- bad reactions you may have to certain medicines
It also includes your name, address, date of birth and unique NHS Number which helps to identify you correctly.
An SCR is used in a number of healthcare settings and will provide healthcare professionals with any information they wouldn't otherwise have. For example, when you're visiting an urgent care centre or being admitted to a hospital, staff could view your SCR and discover you are on a particular medication or have allergies.
Watch or download the materials below for more detailed examples
Can I add more information to my Summary Care Record?
You can choose to add any information to your SCR that you think will help improve your care. This can be of particular benefit to patients with detailed and complex health problems. You and/or your carer should discuss anything you wish to add with your GP.
If you are a parent or guardian of a child under 16 and feel that your child is able to understand this information you should show it to them. You can then support them in the decision to maintain an SCR and whether to include additional information.
Also read the advice leaflet adding more information to your record (PDF, 420kb).
Who can access or view my SCR?
Only authorised healthcare professionals directly involved in your care can access your SCR. Your SCR will not be used for any other purposes. The person viewing your SCR:
- needs to have an NHS Smartcard with a chip and passcode
- will only see the information they need to do their job
- will have their details recorded every time they look at your record
In addition, the healthcare professional must seek your permission if they need to look at your SCR. If they cannot ask you because you are unconscious or otherwise unable to communicate, they may decide to look at your record because doing so is in your best interest. This access is recorded and checked by the Privacy Officer of the organisation to ensure it is appropriate. Find out more about information governance from the HSCIC.
Can I opt out of having a Summary Care Record?
You can choose to opt out of having an SCR at any time. If you do opt out, you need to let your GP practice know by filling in an opt-out form (PDF, 245.9kb). If you are unsure whether you have already opted out, you should talk to the staff at your GP practice.
If you change your mind, simply ask your GP to create a new SCR for you. For more information about Summary Care Records, contact firstname.lastname@example.org, phone 0300 303 5678 or visit the HSCIC's website. Alternatively,
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. Camden in London is one of the first CCG areas to introduce this. Find out more on the Camden's CCG website.
Other CCGs may offer similar schemes or entirely different ones. Visit your CCG's website or contact the CCG directly for more information.