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Your health and care records

What is meant by health record?

Health records

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. 

Tip

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
  • X-rays
  • 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 enquiries@hscic.gov.uk, 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.

Sharing data from your records 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.

TipBesides the data collected by hospitals, the NHS also collects similar information at a local level, from GP practices, to help 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.

Page last reviewed: 07/03/2016

Next review due: 07/03/2018

Keeping your online health and social care records safe and secure

Guidance is available to help you understand what an electronic health and care record is, how you can access it, who you may want to share it with, and how to perform these actions securely. This guidance was created by the Department of Health, working in collaboration with BCS, the Chartered Institute of IT, in 2013.

Download the patient guidance booklets:

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