GPs can include additional information by changing the patient's consent status on the clinical system used in the practice, to 'Express consent for medication, allergies, adverse reactions and additional information'. (This functionality was included in release SCRv2.1 of SCR, which is available on Emis Web, TPP Syst mOne and InPractice Vision.) Staff need activity B0020 on their smartcard to do this. It adds read code 9Ndn or CTV3 code XaXbZ to the record. Once consent status is changed, coded items and the supporting free text will be added. This will include:
- significant medical history (past and present)
- reason for medication
- anticipatory care information (such as information about the management of long term conditions)
- end of life care information (from the SCCI1580 national dataset)
This information is identified within the system through the codes for significant medical history (known as active problems and significant past problems, local summary and active problems, or priority 1 items and active problems, depending on which clinical system is being used) or those included in the NHS Digital SCR inclusion dataset (overview). (To see the complete list of codes currently in the inclusion set used by GP suppliers implementing SCR v2.1, download the NHS Digital SCR inclusion dataset)
Specific sensitive information like fertility treatments, sexually transmitted infections, pregnancy terminations and gender reassignment will not be automatically included when the information is added. Sensitive information is excluded through the RCGP sensitive dataset. These documents are for reference only, and full downloads of the GP Summary Code List releases are available on the Technology Reference Data Update Distribution site: https://isd.hscic.gov.uk/trud3/user/guest/group/0/pack/1/subpack/141/releases.
Other items, including sensitive items that the patient would like to be included, can be manually added to the record. The patient can view a preview before they consent, and items can be added or removed.
View an example SCR with additional information created by TPP SystmOne
View an example SCR with additional information created by Emis
Identification and management of patients with frailty
From 1 July 2017, the General Medical Services (GMS) contract requires GPs to identify patients with moderate or severe frailty, and promote the inclusion of additional information in the SCRs of those with severe frailty by seeking their consent to add it. NHS Digital have sent a resource pack, Supporting Guidance for promoting enriched Summary Care Records for patients with frailty, to CCGs, to be distributed to GP practices, containing support and guidance on their new duties and how to include additional information in SCRs.
Read NHS England guidance on the requirements to support frailty in the GMS contract 2017-18.