Incorporating Summary Care Record (SCR) Information into the Local Detailed Care Record
Information from various sources (such as a GP letter, a handover form or the content of the SCR) may be used to inform clinical decisions in a variety of care settings and, in line with NHS record keeping policy, may need to be added to the local detailed care record to document what information was used in the treatment of patients and when.
Incorporation of information in the local detailed care record applies whether the information is electronic or paper based and, as per current IG controls, should only be looked at by authorised users.
In order to include the information that has been used from the SCR, a clinician can add the information to the local detailed care record either electronically or manually. For example:
- Printing the SCR at a point in time to add to paper record (as per current processes where GP letters detailing repeat medication lists are added to the patient file on admission)
- Importing information from one system to another
- Copying and pasting from one system to another
- Transcribing to local notes (manually writing information from one source to another)
A user needing to treat a patient can choose any of the above methods of recording the information they used to base their decisions on, depending on their preference, system availability and local policy.
To be able to record information from the SCR in a local detailed care record, a user must first have the access rights to view SCRs, including the following IG controls:
- Smartcard with the appropriate RBAC
- Legitimate relationship with the patient (clinical need to refer to the SCR)
- Permission to view the record from the patient
It is important that the user is aware of the implications of incorporating SCR information in the local detailed care record and the process steps that need to be undertaken. These may already be covered by existing local governance around incorporating clinical information into local detailed care records. The process steps are detailed below. A user must:
- Ensure the date and time of the SCR creation is included with the incorporated information. This will be automatically included if the SCR is printed out or imported from another system but may need to be manually included if copying and pasting information from one system to another. Or writing the information down.
Remember: the information in the SCR is a snapshot in time of the patient’s clinical information, and may subsequently change when the GP updates the patient’s record. Therefore, if it is ever referenced, the SCR creation date and time will be important to understand what the content was at that point in time.
- Ensure that the source of the information is documented – i.e. that it is from the SCR.
- Ensure that all data is incorporated from the SCR where possible. Incorporating partial information will mean that there is incomplete record keeping and could cause confusion for subsequent healthcare staff viewing the local detailed care record.
- Ensure that there is a record of who incorporated the data into the local detailed care record. This process will depend on local arrangements. For electronic solutions, this may be managed within the IT system. For paper systems, the local policy for handling the incorporation of clinical information should be followed.
Once the SCR information has been either incorporated into the local system or added to the local paper record, it will then become part of the local detailed care record and the existing IG controls governing those records by the local trust will apply.
When information from the SCR has been incorporated into the local detailed care record, it is technically no longer the Summary Care Record as it will not contain any changes made over time by the GP. Therefore, as noted, it is only a copy of the SCR information at a point in time and is to be considered reference data to be used for that episode of care. If the patient presents to the same care setting again, the current SCR should be viewed on each occasion.
Frequently Asked Questions on Incorporating SCR Information
Who can incorporate SCR information into the local detailed care record?
Users with the relevant RBAC to view SCRs can incorporate information into their local detailed care records. It is a local decision to allow the incorporation of SCR information and this may be documented as part of the local implementation and new ways of working to include viewing of SCRs.
What SCR information can be incorporated into the local detailed care record? Is it possible for a clinician to omit parts of the SCR information if it is deemed to be sensitive?
All the relevant details that have been used to inform clinical decision making should be incorporated into the local detailed care record. It is advised that, where practicable, all clinical information from the SCR should be recorded rather than partial or selected information.
However, the decision rests ultimately with the clinical user who should use their judgement as they would currently, when noting down information from other sources (including the patient).
N.B. Once incorporated, the information should not be deleted from the local detailed care record as it forms the audit trail/record for the patient’s treatment.
Is it necessary to ask the patient explicitly for their permission to incorporate Summary Care Record information into the local Detailed Care Record?
Patients have a choice about whether or not to allow clinicians to view their Summary Care Record and they will be asked their permission every time it needs to be viewed, including the scope of the request and who it is for.
It is therefore not necessary to ask patients their explicit consent to incorporate Summary Care Record information into the local detailed care record. Similarly where the Summary Care Record is viewed without permission but in the best interests of the patient (e.g. if the patient is unconscious) the same rules apply, in that if the decision has been made in the best interest of the patient, then this covers incorporating the use of SCR information accordingly.
However, it is worth noting that currently, information gained from the patient or other sources is added to the local detailed care record without explicit patient consent e.g. when taking patient history or adding a GP letter because this is part of good record keeping to support patient care. If a trust wishes to discuss incorporating SCR information into the local detailed care record with their patients, this should be documented as part of local processes.
How does caching SCR information differ from recording SCR clinical information?
An integrated system (existing system with SCR viewing functionality incorporated into it) may cache copies of the GP Summary to the local detailed care record. Caching allows a system to store a copy of SCR clinical information (either temporarily or permanently) in order to use it when treating the patient or to add the information to the audit trail.
Users must go through the standard IG controls for SCRs to access the cached information including being allocated the correct RBAC, using their smartcard, creating a legitimate relationship and gaining permission to view. Once the episode of care has ended, the cached copy can either be automatically deleted from the local detailed care record and will need to be re-requested if the patient returns for treatment; or stored to the audit trail as part of the local detailed care record. Once it has been added to the local detailed care record, it is subject to local IG controls for those records.
• Scotland’s Emergency Care Summary (ECS): Printing the ECS