Ensuring the safety of patients.
The NHS in England is introducing the NHS Care Records Service to improve the safety and quality of patient care. It will give health-care staff faster, easier access to reliable information about you to help with your care.
Health-care staff can usually only share information from your records by post, email, fax or phone. This can cause delays in making sure that the right people receive the right information as quickly as possible. Now there will be quicker ways to get important information to staff treating you. This will be particularly useful in an emergency.
What information do you keep in my health-care records?
We keep information relating to your care so we can provide you with safe, effective care. The information we keep falls into two categories.
“The NHS Care Records Service is all about creating and linking up electronic records to improve the way we care for you.”
Demographic information
This includes your name, address and contact details.
Clinical information
This includes details of any medicines, allergies and health conditions.
What is the NHS care records service?
Currently each NHS organisation responsible for your care keeps its own records about you and your treatment. This information is currently stored on a combination of paper-based and computer systems. You may have noticed that you can often be asked the same questions about your medications or your condition when you’re at different NHS organisations for treatment, or even within the same place if you’re at a different clinic or department.
We will be creating and linking up electronic records, both within one particular organisation and also with other organisations where you may receive care, such as hospitals, GP practices and clinics. This will mean that the health-care staff treating you will be able to get a better understanding of your needs. This is because they will have access to information about your care, where and when they need it, using a secure computer system.
What are detailed care records and summary care records?
Detailed care
records
Your detailed care records will be available to NHS staff treating you and will contain the same sort of information that we currently hold about you.
The difference is the way that the information is shared between NHS organisations. This will be done securely and electronically and the staff involved in your care will be able to see the information they need to treat you, where and when they need it.
Summary care records (SCR)
Your summary care record will be available to NHS staff providing you with care anywhere in England.
At first, they will contain important health information such as details of your allergies, current prescriptions and bad reactions to medicines. After that, each time you use any NHS health services, we may add details about any current health problems, summaries of your care and the professionals treating you to your SCR. Your SCR will be of most benefit if you need health care in an emergency or if you are away from home in England and need treatment.
“We keep information relating to your health so that we can provide you with safe, effective care.”
Your Choices
- You can choose not to share your detailed care records between NHS organisations. For information about how to do this, please talk to a member of staff at your local NHS organisation.
- You can choose whether or not to have SCRs. When we introduce them in your local area, we will write to you and let you know about your choices. For more information about SCRs, visit www.nhscarerecords.nhs.uk or phone our Information Line on 0845 603 8510.
- If you decide not to have summary care records, it will not affect the other part. You may choose to share your detailed care records across NHS organisations but may prefer not to have SCRs, or you may be happy to have SCRs but choose not to share your detailed care records.
How will this benefit me?
You visit your GP as you feel unwell.
The GP treats you and records this information, including medication, in your electronic GP record (which forms part of your detailed care records). We then update your SCR with this information (for GP practices which have introduced SCRs).
Later in the week you visit a clinic at your local hospital for another health condition.
The hospital doctor wants to change your medication and asks your permission to look at your SCR. Seeing that the medication prescribed by your GP may react negatively with what they were about to prescribe, they choose a different medication for you. They then add this information to your detailed care records and arrange for you to see a district nurse in the community for follow-up treatment.
You go for your first appointment with the district nurse, who can see information on you from your detailed care records.
The district nurse can start treatment quickly and safely as they have the information they need immediately.
Your GP can also see the relevant information recorded by clinicians who have treated you since you last saw them.
Respecting your confidentiality
By law, everyone working for or on behalf of the NHS must respect your confidentiality and keep all information about you secure. In every place where you’re treated by the NHS, there are people responsible for protecting your confidentiality. These people are often known as 'Caldicott Guardians'.
The NHS published the NHS Care Record Guarantee for England. This says how we will collect, store and access your electronic records, and sets out your options to take part in the service. See the end of this leaflet for details of how to get a copy.
We will use the strongest national and international security measures available for keeping your information safe and secure.
How will you control access to my care records?
Any member of staff looking at your care records:
- Must be involved in your care.
- Must have an NHS Smartcard, with a chip and passcode (like a bank card and PIN)
- Should only see the information they need to see to do their job.
- Will have their details recorded – who they are and if they have added or changed any of your information.
All staff who are able to see patient information have a professional, ethical and legal responsibility to keep your details secure and confidential.
Will you transfer all my paper records into electronic NHS Care Records?
The NHS published the NHS Care Record Guarantee for England. This says how we will collect, store and access your electronic records, and sets out your options to take part in the service. See the end of this leaflet for details of how to get a copy.
We will use the strongest national and international security measures available for keeping your information safe and secure.
When will we start using the NHS Care Records Service?
Some NHS organisations in the North West are already using parts of the NHS Care Records Service. We are introducing the service in stages over the next few years. We have given you this leaflet because the NHS organisations providing your care will soon be joining the service. You can ask a member of staff at your local NHS organisation for more information about when this will happen.
“By law, everyone working for or on behalf of the NHS must respect your confidentiality.”
Can I see what’s held on my health records?
We respect the rights of individuals to inspect or get a copy of information held about them. Please ask a member of staff at your local NHS organisation for more details about this.
Other ways to limit who sees your health information.
You may be happy with the idea of sharing information, but could have concerns about certain aspects being seen by all medical staff involved in your care.
For example, this may be information about a condition you may not want people to know about. In this situation, you may be able to ask that this information is 'sealed'
(sometimes known as creating a ‘sealed envelope’). If we seal information, it restricts the amount of information health-care staff can see without first asking for your permission. However, this can be ignored in exceptional circumstances, for example, if there is a court order.
If anyone tries to see the sealed information, it will trigger an alert to the Caldicott Guardian who may investigate the matter.
We are gradually introducing sealing to different computer systems across the country. You may not yet be able to seal information at all NHS organisations where you receive care. Ask a member of staff for more information.
Further Information
To download a copy of the NHS Care Record Guarantee and other information leaflets; or for more information about the NHS Care Records Service please visit: www.nhscarerecords.nhs.uk.
For more information about the changes to patient record keeping being introduced at University Hospitals of Morecambe Bay NHS Trust, visit www.mbht.nhs.uk.
If you have any questions about the NHS Care Records Service, please telephone the dedicated information line on 0845 603 8510.
