The SCR contains a core data set of medication, allergies and adverse reactions.  Additional information such as diagnoses or care plans can be added to the SCR by the GP Practice with the explicit consent of the patient.  Patients who wish to have additional information added to their SCR should discuss their wishes with their GP Practice. 

This webpage is a resource for NHS staff and brings together key guidance for managing additional information and the SCR.  It covers the following topics: 

• Patient consent for additional information
• Content of additional information
• Guidance on how to add additional information
• Guidance for NHS Staff implementing additional information in their local health community
• An example of how additional information in the SCR can be used to support patient care through communicating end of life wishes

A business process map (PDF, 65.3kB) to support clinicians and project managers understand the process of adding additional information to a patient's SCR with their explicit consent is available.

Patient Consent for additional information

Patients must give their explicit consent prior to additional information being added to their SCR.  A guidance document to support clinicians implementing explicit consent for additional information (PDF, 246.9kB) is available.  This document consists of 6 key principles, contains practical examples of how these principles can be implemented and references the appropriate professional regulatory guidance that underpins all consenting processes.

Before additional information can be added to the SCR, the patient's consent preference must be updated in the GP IT system.  Guidance on how to update and manage the SCR consent preference (including the new SCR consent codes) is available.

Content of additional information

Patients requiring urgent and emergency care may have complex health care needs and / or a long term condition.  For those patients, additional information can support their care.  For example, diagnoses or contact details of health care staff involved in their care.  Patients may want additional information available in their SCR, for example, patients approaching the end of life may want their end of life preferences available in their SCR.

Clinicians who are using SCR in urgent and emergency care settings have indicated that additional information in the SCR can increase their ability to make informed clinical decisions. 

Examples of additional information that can be added by GP Practices to an SCR include:

• Diagnoses eg asthma, diabetes mellitus, myocardial infarct, stroke, rheumatoid arthritis, cancer, epilepsy
• Patient preferences eg preferred place of care, resuscitation status
• Care plan information eg asthma care plan, diabetes care plan, palliative care plan
• Significant events eg operations
• Immunisations

The Good Practice Guidelines for GP electronic patient records V4 (2011) gives guidance to GP Practices regarding what information could be considered for inclusion in the SCR from the GP record.

The GP Practice and patient should be confident that any additional information they choose to share through the SCR is of a quality that is fit for sharing.  Further guidance on information fit for sharing through the SCR is available.

Guidance on how to add additional information using the GP IT system

Additional information can only be added to the SCR from the GP IT system.  A high level overview of how to manage additional information from GP IT systems (PDF, 1.3MB) has been developed.  System specific training is available to support GP Practices understand how additional information can be added in their IT system.  This can be accessed through your system supplier or local SCR implementation team. 

Automated demonstrations have been developed to illustrate how additional information can be added using the following GP IT systems:

• SystmOne TPP
• InPS Vision
• EMIS LV – due December 2011
• iSOFT Synergy – due December 2011
  

Guidance for NHS Staff implementing additional information in their local health community

GP Practices may choose to add additional information on a patient-by-patient basis.  Alternatively they may choose to approach certain patient groups within their Practice, for example patients with long term conditions, and add additional information for these groups.  The documents and advice on this web page should provide the guidance they need to manage this process. 

However, some local health communities may wish to facilitate the adding of additional information in a more structured manner through a defined project.  For example, a project to support patients with long term conditions or for those approaching the end of life.  Guidance and a project plan have been developed to support NHS staff where a defined project is being considered based on lessons learned from sites that are using additional information. 

Additional information project guidance (PDF, 128.4kB)   
Additional information project plan (ZIP, 25.0kB)

An example of how additional information in the SCR can be used to support patient care through communicating end of life wishes

Historically, the profile of end of life care has been low and care has been variable across the country.  Whilst some people die as they would have wished, many others do not and some experience unnecessary pain and other symptoms.  In order to deliver high quality end of life care, good communication and coordination between healthcare professionals is essential.  In particular, everyone involved in a patient's care should be aware of their wishes and issues through a care plan.  

Some local health communities are using or developing plans to use SCR to support the communication of end of life information by making end of life care plan information available to those delivering care to the patient.

This patient journey illustrates how the Summary Care Record can support the care of a patient who is approaching the end of life.