Your Health Record

Health Records in the NHS

When you visit an NHS or social care service, information about you and the care you receive is recorded and stored in a health and care record.

This is so people caring for you can make the best decisions about your care.

The information in your records can include your:

  • name, age and address
  • health conditions
  • treatments and medicines
  • allergies and past reactions to medicines
  • tests, scans and X-ray results
  • lifestyle information, such as whether you smoke or drink
  • hospital admission and discharge information

 

Your GP Record

GP records include information about your medicine, allergies, vaccinations, previous illnesses and test results, hospital discharge summaries, appointment letters and referral letters.

You can access your GP records, and nominate someone you trust to access them, through our online services. More information about what online services are available, how to access them, and things to consider when accessing health care online can be found on our Online Services page.

All patients registered with a GP surgery also automatically have a Summary Care Record unless they have chosen not to have one. This is so that some details about you can be accessible by, for instance, an A and E department in an emergency. You can read more about your Summary Care Record and how to inform us about your preferences below.

 

How we use your information

The primary way in which we use the information we store about you is so that we can offer you relevant treatment. We record information you give us alongside details about your care because it is needed if we see you again.

We may use some of the information in your health record for other reasons, for example:

  • In assuring and improving the quality of your care and treatment
  • In the protection and monitoring of public health, for example controlling infection
  • In the managing and planning of the Health Service
  • In the investigation of complaints and legal claims
  • For medical or health service research, audit and training

Sometimes the law requires us to pass on information, for example 'Statutory notifications of births and deaths'. Where possible the information is anonymised, so the details cannot be traced back to an individual patient.

Summary Care Records

A Summary Care Record is a way of telling health and care staff important information about a person. All patients registered with a GP have a Summary Care Record, unless they have chosen not to have one.

The information held in your Summary Care Record gives health and care professionals, away from your usual GP practice, access to information to provide you with safer care, reduce the risk of prescribing errors and improve your patient experience.

For people with long term health conditions, one of our doctors might ask if they can add some additional information to the summary care record. This Additional Information includes information about significant medical history (past and present), reasons for medications, care plan information and immunisations. This will mean if a person needs treatment by other services like emergency or urgent care they will have more information about them.

During the coronavirus pandemic period, your Summary Care Record will automatically have Additional Information included from your GP record unless you have previously told the NHS that you did not want this information to be shared.

More information about the Summary Care Record, including an easy read leaflet, is available on the NHS Digital website.

You cannot get your Summary Care Record online. If you'd like to see it, please contact the practice.

Summary Care Record Opt Out

The purpose of the Summary Care Record (SCR) is to improve the care that you receive, however, if you don't want to have an SCR you have the option to opt out. If this is your preference please inform your GP or fill in an SCR opt-out form and return it to the Practice via email or hard copy.

Regardless of your past decisions about your Summary Care Record consent preferences, you can change your mind at any time. You can choose any of the following options:

  1. To have a Summary Care Record with Additional Information shared. This means that any authorised, registered and regulated health and care professionals will be able to see a enriched Summary Care Record if they need to provide you with direct care.
  2. To have a Summary Care Record with core information only. This means that any authorised, registered and regulated health and care professionals will be able to see information about allergies and medications only in your Summary Care Record if they need to provide you with direct care.
  3. To opt-out of having a Summary Care Record altogether. This means that you do not want any information shared with other authorised, registered and regulated health and care professionals involved in your direct care, including in an emergency.

To make these changes, you should inform the Practice in writing or complete the SCR patient consent preferences form and return it to the Practice.

Sharing Your Medical Record

Increasingly, patient medical data is shared between different healthcare organisations. One example of this is record sharing 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 to other health providers and must also consent to which of the other providers can access their data. For more information about how we use your data and the safeguards that are in place, please visit our Data Protection page.

Access to your Health Records

The General Data Protection Regulation of May 2018 gives you right of access to all information the practice and the Primary Care organisations hold about you, both on manual records and the computer. It is your legal right to see your records and, if you so wish, to obtain a photocopy of them.

Only in exceptional circumstances can access be withheld. If you would like to apply for access to information held about you, or would like further information about the Act, please discuss this with the person in charge of your care or write to the Practice Manager at the surgery address.

Practice Manager
The Lavender Hill Group Practice
19 Pountney Road
Battersea
London SW11 5TU