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The Summary Care Record (SCR) is an electronic record of important patient information created from GP medical records. It can be seen and used by authorised staff in other areas of the health and care system who are involved in the patient’s direct care. Therefore, the GP medical records must be up to date so that the SCR can provide a full picture of the patient to be able to treat them safely.
Not all medications are prescribed by a GP at a GP practice. Other care settings, for example Accident and Emergency departments, community pharmacies, paramedics and dentists can also prescribe medication to patients, including repeat medication. If these medications are not recorded back into the GP practice record, it could result in healthcare professionals not having enough information to make an informed clinical decision about a patient’s care.
How to record medicines prescribed elsewhere into the GP practice record
When GP practices receive a patient’s, discharge note from an alternative care setting or is made aware of any medication from another care setting, information on any prescribed medications should be added to their GP practice record.
Here are the high-level instructions on how to do this across the four principal GP system providers;
Once in a patient record, enter the drug details as normal on the ‘add a drug’ screen, ensuring that either ‘acute’ or ‘repeat’ is selected as appropriate and then select ‘issue’.
The ‘Issue’ screen is then displayed. It is this screen where the user is able to change where or how the medication has been prescribed. Select “Change All” at the top of the screen and select “Hospital (No Print)” for a medication prescribed at a hospital (for example). Once this has been done, follow the steps by clicking the ‘Approve and Complete’ button.
Medications entered in this way will appear on the patient’s SCR under the medication “type” heading stating ‘Repeat Prescribed Elsewhere’.
Further options of ‘Record For Notes (No Print)’ and ‘Over The Counter (No Print)’ are also available if required.
Once in a patient record, Right-click on the ‘Medication’ node of the Clinical Tree and Select ‘Record Other Issue’. Enter the name of the medication you are recording in the ‘Drug and Appliance Browser’ window and click ‘Search’.
Select the particular formulation of the drug you require and click Ok.
Choose a ‘Medication Source’ (Other, Dental or Hospital) and enter any information about the dose and quantity that you have. Click Ok.
Once the record is saved any medications added following the above will appear in the patient’s SCR under the heading “Current Repeat Medications”, medication type ‘Repeat Prescribed Elsewhere’ with text appended “This medication could be either Acute or Repeat medication”. Please check with the patient and/or carer(s) to clarify this detail”.
Once in a patient record, navigate to the ‘Repeat Master - Add’ screen and choose ‘Source of Drug’ options (Self Prescribing, By Hospital, By Health Carer in another Practice, By GP in another practice).
Next select the drug and quantity and click Ok. Then save the record.
Once the record is saved any mediations added following the above will appear in the patient’s SCR under medication “type” heading stating ‘Repeat Prescribed Elsewhere’.