Patients with Full SCR Consent

From Summary Care Record (SCR) release v2.1, an improved mechanism to make it easier for GPs to create SCRs with additional information for patients with full SCR consent, 9Ndn. Express consent for core and additional SCR dataset upload.

This can be used to benefit such as ‘end of life’ patients, the 'frailest 2%' and those with long term conditions and/or communication problems such as those with learning disabilities or dementia; or indeed any patient that feels that it would be beneficial to have additional information about their care/health added to their SCR. Existing patients with additional information in their SCRs have this supplemented with additional relevant information as described below. Adding additional information remains within the control of individual patients and their GPs. The patient’s express consent is required for additional information to be included on the SCR. If the patient’s consent for additional information is recorded, the SCRcontains:

  • Medications, Allergies and Adverse Reactions, plus the reason for medication.
  • The following additional information:

    • Significant problems (past and present)

    • Significant procedures (past and present)

    • Anticipatory care information

    • End of life care information, as per EOLC dataset ISB 1580

    • Immunisations

The information added to the SCR consists of coded items from the GP record with their supporting free text. When the SCR is populated with the additional information, you can preview the SCR content to ensure sensitive information is not included.

You can add further individual items, for example, this can be used to include relevant items not automatically included or sensitive items that the patient would like adding to the SCR. The SCR is automatically kept up to date with the relevant information above as the GP record is updated over time.

See Additional Information for details of automatically included data.

Patients can be reassured that potentially sensitive items, for example, IVF, STDs, terminations, gender re-assignment, are automatically excluded unless the patient wants them including. If so, the patient must provide consent for their GP to add them.

See Summary Care Record (SCR) Withheld Data for details of automatically excluded data.

The lists of Read codes used for inclusion and exclusion are set by NHS England and Vision 3.

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