Records Held At The Practice
Your GP Patient Record includes the following information:
- Appointments – dates, who you saw, notes on reason for visit, history, examination, outcome
- Medical diagnoses, investigations & procedures
- Test results
- Letters between your GP and others such as hospital consultants (if your GP believes that information in the records would cause serious harm to your physical or mental health, they are entitled to refuse access to some or all of your records. Access may also be withheld if the records relate to, and identify, another person.)
- Links to information about your diagnoses/treatments.
Records Available To Other Health Staff
The NHS holds a Summary Care Record (SCR) for each patient. An SCR is an electronic record held centrally which contains brief information about the medicines you take, allergies you suffer from and any bad reactions to medicines you have had.
Accessing Your GP Record
You can view your medical records online if you are registered for Online Access.
Sharing Your Medical Record
Increasingly, patient medical data is shared e.g. between GP surgeries and District Nursing, in order to give clinicians access to the most up to date information when attending patients.
The systems we operate require that any sharing of medical information is consented to by patients beforehand. Patients must consent to sharing of the data held by a health provider out to other health providers and must also consent to which of the other providers can access their data.
e.g. it may be necessary to share data held in GP practices with district nurses but the local podiatry department would not need to see it to undertake their work. In this case, patients would allow the surgery to share their data, they would allow the district nurses to access it but they would not allow access by the podiatry department. In this way access to patient data is under patients' control and can be shared on a 'need to know' basis.
Emergency Care Summary
There is a Central NHS Computer System called the Emergency Care Summary (ECS). The Emergency Care Summary is meant to help emergency doctors and nurses help you when you contact them when the surgery is closed. It will contain information on your medications and allergies.
Your information will be extracted from practices such as ours and held securely on central NHS databases.
As with all systems there are pros and cons to think about. When you speak to an emergency doctor you might overlook something that is important and if they have access to your medical record it might avoid mistakes or problems, although even then, you should be asked to give your consent each time a member of NHS Staff wishes to access your record, unless you are medically unable to do so.
On the other hand, you may have strong views about sharing your personal information and wish to keep your information at the level of this practice. If you don’t want an Emergency Care Summary to be made for you, tell your GP surgery. Don’t forget that if you do have an Emergency Care Summary, you will be asked if staff can look at it every time they need to. You don’t have to agree to this.