What is a medical/health record?
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 etc.
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.
Paper and electronic records contain:
- 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
- Results of other tests and investigations
Access to Health Records governed by Data Protection Act (1998)
Some GPs have given online access to their patients’ GP records for some time. From April 2015 all GPs should give their patients online access to summary information in their records. This is part of the drive to provide more GP online services to patients. It should give you more control of your health and well-being, especially if you are managing a condition that needs regular monitoring and frequent prescriptions.
- If you want to view medical records held by other NHS services you need to make a formal request under the Data Protection Act (1998) and apply in writing to the holder(s) of the records.
- If you wish to view your medical records online please sign up at Reception (you will need to provide photo ID)
- If you wish to see a paper version, please write to your GP or the practice manager.
- If you want to see your hospital records, write to the hospital’s patient’s services manager or medical records officer.
If you think that information in your health records is incorrect or your need to update your personal details (name, address, phone number), please contact the practice in writing and let us know what needs changing.
We can not change clinical records that have been previously recorded, although we can add supplementary comments if you wish to clarify statements that have been made (especially if you disagree with them).
Local Care Record
To enable information-sharing to happen more quickly and to improve the care you receive, a new process has been put in place in Lambeth called the Local Care Record .
Through existing computer systems, this will join up care records held on your GP practice with the three main local hospital organisations: Guy’s and St Thomas’, King’s College Hospital and South London and Maudsley NHS Foundation Trusts.
Information is only shared when it is needed to make your care and treatment safer, easier and faster and only with those people directly involved in your care. This could include allowing a hospital doctor to see the medication that a GP has prescribed for you when you go into hospital or allowing a GP to see what care, tests or treatment you received while in hospital.
Whenever possible, professionals will inform you that they are accessing your care record. This may not be possible every time, for example in an emergency, however each time a person accessing your information there is a clear record of it.
Summary Care Record
This is sharing your data within the NHS. e.g if you are seen in A&E.
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.
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.
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.
You can contact this number for more information 0300 123 3020
Summary Care Record opt out form
Please complete this form and return to the practice.
Please note. Opting out of one does not imply you have opted out of both. You must complete both forms if you wish to opt out of both.