Currently, most patients have an SCR containing the ‘core’ dataset SCR (medication, allergies and adverse reactions as a minimum). SCRs can also contain Additional Information over and above the core dataset where patients provide their explicit consent for this to happen. 

During the COVID-19 pandemic, all patients without an express preference status (to opt-out of SCR or to have a core SCR) will temporarily have an SCR with additional information created for them. Unless alternative arrangements have been put in place before the end of the COVID-19 pandemic, this change will then be reversed.

Existing preferences for the sharing of Summary Care Records will be respected and applied. For patients who have previously expressed a preference to either opt-out or have a core Summary Care Record only, their preferences will continue to be respected.  Patients will still have the same options that they currently have in place, including the opportunity to opt-back in to sharing this information.

To support the response to COVID-19, a specific set of COVID-19 related SNOMED codes have been temporarily added to the SCR inclusion dataset to maximise the information made available from General Practice. The necessity to maintain this specific content in the SCR will be reviewed and removed when it is no longer relevant.

The core SCR dataset present in all records is:

• allergies and adverse reactions to medication
• current repeat medication
• last 12 months of acute medication (unless otherwise stated)
• last 6 months of discontinued repeat medication (unless otherwise stated)

The SCR is sourced from the patient’s GP record only. Therefore, it may not include the entire list of the patient’s over-the-counter medications or items prescribed outside of the GP practice, unless the practice has manually entered these items into their GP system or the information is part of a wider shared record from another organisation. These items will be labelled on the SCR (under Type) as ‘Prescribed Elsewhere’.

The SCR is marked with the last date and time that an update was sent by the GP practice. Viewers should check this to ensure that they understand when the record was last updated.

A message will be displayed if a patient has recently changed their GP practice, as this could indicate that the SCR content is not yet fully up to date . A message will be displayed if the SCR has been newly created or has not yet been created by the patient’s new GP practice; either because the new GP practice does not yet hold information to overwrite the existing SCR, or because they have not yet started uploading SCRs. These messages, in conjunction with the date and time stamp, should be used to assess how current the SCR information is.

A message will be displayed when items have been withheld from the SCR. This may be because GP system privacy settings have been used to restrict the sharing of certain information from the patient’s GP record.

Figure 1: Viewing the core SCR

Functionality has been enabled in GP systems (with the exception of Microtest) for Additional Information to be added to a patient SCR with ease.

Additional Information may include:

• reason for medication 
• significant medical history (past and present) 
• significant procedures (past and present) 
• anticipatory care information – such as information about the management of long term conditions
• communication preferences – as per the DCB1605 dataset
• end of life care information – as per the SCCI1580 dataset
• immunisations
• COVID-19 related information (temporary change)

Additional Information includes relevant codes from the GP record relating to accessible information requirements, details of carers, lasting power of attorney and other information to facilitate reasonable adjustments required under the Equality Act (2010).

Items are identified for inclusion due to their presence above either as part of a key dataset (such as end of life care) or because they appear in a relevant section of the GP record. For example, items appearing as ‘significant problems’ within the GP system are likely to be automatically included. GP practices may also manually add further information, in accordance with patient wishes.

Patients who benefit most from additional information are:

• those approaching the end of life
• patients with frailty
• those with long term conditions and/or communication problems such as patients with learning disabilities or dementia

From 1 July 2017, the General Medical Services (GMS) Contract required GP practices to routinely identify moderate and severe frailty in patients aged 65 years and over. Practices are required to seek informed patient consent to activate the enriched SCR for patients identified with severe frailty.

Figure 2: Viewing Additional Information in the core SCR

There are a number of differences in the way that information is recorded between the different GP systems and the different GP system supplier implementations. There are also differences due to local data quality, recording practices and patient preferences. As a result, the content of SCRs with Additional Information will vary from one record to another but will follow a broadly consistent presentation format. However, a consequence of this is that a small number of patient’s SCRs will not include major past problems and other SCRs will not include all instances related to a specific code.

SCR content is limited to information held in GP systems but may include information from shared records. Therefore, the SCR Additional Information may include relevant content recorded by other organisations and shared with the GP practice.

The data included in the SCR consists of coded items from the GP system together with any supporting free text. Some of the primary care terminology may not be familiar to emergency and other secondary care clinicians. There is no standard for the recording of supporting free text and its quality will vary, but when present in the SCR it generally provides additional useful detail to supplement the coded information. This may also include information that may be considered sensitive or relate to unnecessary third party information – see Summary Care Record exclusion set below.

The SCR with Additional Information is generally larger - typically 2-3 times the size of the core SCR (3-16 pages).

The SCR with Additional Information follows the existing SCR format with the core dataset of the record containing medications, allergies and adverse reactions remaining at the top of the SCR. When Additional Information has been added, 'Reason for Medication' will appear against relevant medication if this has been recorded by the GP practice.

Additional Information will appear below the core SCR, grouped under the following Care Record Element (CRE) headings:

• Risks to Patients
• Administrative Procedures
• Risks to Care Professional or Third Party
• Provision of Advice and Information to Patients and Carers
• Diagnoses
• Personal Preferences
• Problems and Issues
• Services, Care Professional and Carers
• Clinical Observations and Findings
• Care Professional Documentation
• Treatments
• Patient/Carer Correspondence
• Investigations
• Third Party Correspondence
• Investigation Results
• Social and Personal Circumstances
• Family History
• Lifestyle
• Care Events

The headings are determined by the UK Terminology Centre (UKTC) and are a mechanism to group SCR items within individual patient records. A heading will only appear in an individual SCR if there is relevant information available from the patients GP record for inclusion under that heading. Some headings are only likely to be used in limited circumstances. For example, ‘Third Party Correspondence’ will not generally be present as this information cannot currently be attached to the SCR – although the existence of correspondence in the GP record could be signposted. When headings are shown, they always appear in the order above.

There is no specific ‘End of Life’ heading but End of Life care information will appear under relevant headings. For example, information about resuscitation status will always appear under 'Personal Preferences' and diagnoses will appear under 'Diagnoses'.

The quality and completeness of the Additional Information included in an SCR is dependent on factors such as the underlying clinical record, data quality and confidentiality issues. SCR viewers should be aware that the SCR may not be complete and should be seen as an additional clinical tool to support current practices.

Items defined in the Royal College of GP’s (RCGP) sensitive datasets which specifically relate to in-vitro fertilisation, sexually transmitted diseases, terminations of pregnancy and gender re-assignment are automatically excluded from Additional Information, but can be manually added by the patient’s GP practice, if the patient wishes.

There may be other items deemed as sensitive which may have been included as codes or referenced in free text, such as details of abuse or unnecessary information related to third parties. Viewers are reminded to treat the SCR information with the same sensitivity as any other clinical records and to take steps to avoid inappropriate disclosure when discussing information with patients, family and carers.

When an item is excluded from SCR Additional Information because it is in the RCGP sensitive dataset, a message is included in the SCR. A general message is included at the top of the SCR indicating that one or more items have been withheld from the SCR.

Figure 3: Viewing Additional Information below the core SCR

There are a number of known causes of duplication and repetition within the SCR with Additional Information. These include duplication of codes from the underlying system, data quality issues, inclusion of repeated vaccinations or different instances of similar information from shared records. Means for filtering these out are being considered.

SCRs may contain auto generated text defining problem detail from the GP system. Examples include Significant Active, Significant Past, Minor Active, Minor Past, End Date, Problem; New – see Fig. 2.

Problems and Issues is a special section that may contain the patient’s active problems, where they have been identified as such in the GP system. Some systems may also include significant past or inactive problems. Any items that appear under this heading will also appear under their respective defined headings as well. For example, heart failure in Fig. 3. appears in 'Diagnoses' and also 'Problems and Issues'.

Immunisations/vaccinations currently appear under 'Treatments'. The SCR is sourced from the patient’s GP record only and it may not include details of the patient’s immunisations administered outside of the GP practice, unless the practice has manually entered these items into their GP system or the information is available as part of a wider shared record from another organisation.

'Clinical Observations and Findings' may include some observation values – such as blood pressure – but only if:

• the GP system adds them systematically (which not all do)
• the GP practice marks the items for inclusion
• they were recorded in a relevant section of the GP record for inclusion in SCR

'Investigations' and 'Investigation Results' only contain items manually added by the GP practice or those items recorded in a relevant section of the GP record for inclusion in SCR.

GP systems use different versions of codes to record clinical information. Some codes may include terminology unfamiliar to non-primary care SCR viewers. Examples of these include:

• [D]= codes for working diagnoses when a specific diagnosis is not yet ascertained
• [M]= related to morphology of neoplasms
• [EC]= Classified elsewhere in a code, usually referring to an underlying cause of a particular disorder
• [NEC]= not elsewhere classified
• [HFQ]= however further classified
• [OS]= otherwise specified - only used when a definitive code is not available     
• [NOS]= not otherwise specified - only used when a definitive code is not available
• [SO]= Site of
• [V]= Supplementary factors influencing health status, but not including illness
• [X][Q] relate to cross-reference and qualifier information - not important for viewing
• A few examples of other clinical notation that may also be encountered include: 
• O/E = On examination
• C/O = Complaining of
• H/O = History of
• P/H = Personal history of
• F/H = Family history of
• CXR =  Chest x-ray
• NAD = No abnormality detected

Figure 4: Viewing Additional Information below the core SCR

The SCR examples shown in this guidance are screenshots of the Summary Care Record application (SCRa). There are some presentation differences between SCRa and printouts.

Further information can be found via the SCR Additional Information web page

For help with implementation or further questions please contact liveservices.operations@nhs.net

COVID-19 information in SCR additional information

A specific set of COVID-19 related SNOMED codes have been temporarily added to the SCR inclusion dataset to maximise the information made available from general practice. This is to support the response to  COVID-19. The necessity to maintain this specific content in the SCR will be reviewed and the content will be removed when it is no longer relevant.

It is important to bear in mind that the SCR has been designed to provide a summary of the GP record but not to provide all of the detailed content. Where COVID-19 information is recorded and coded in the GP record, SCR can help to make this information more widely available.

To interpret this new information, it is important to have an understanding of how these codes are used in GP systems so that SCR viewers can best interpret this information.

During the COVID-19 pandemic period, additional information will be more widely available, including codes from GP systems related to COVID-19 disease encounters, vulnerability, diagnoses presumed or proven, and test results when and where available.

SCR content is limited to information held in GP systems but may include COVID-19 related information from shared records, together with any supporting text. The content may vary, but it generally provides additional useful detail to supplement the coded information.

The quality, presentation and completeness of the COVID-19 related Information included in an SCR is dependent on a number of factors including the underlying clinical record, data quality and confidentiality issues. SCR viewers should be aware that the SCR COVID-19 data may not be complete or exhaustive and should be utilised as an additional data source to support current assessment practice.

Codes related to testing, diagnosis and other COVID-19 codes

Codes related to testing and diagnosis should be interpreted with care, taking account of the dates and sequence to interpret current status and the history of changes.

Suspected cases will only be identified as such where the patient has been in contact with healthcare services and the information has been recorded in a patient’s GP record against specific SNOMED codes. Suspected case information may be recorded in general practice or other healthcare settings and then communicated back to general practice.

Confirmed cases will only be identified as such where the patient has had relevant testing and the information has been recorded in a patient’s GP record against specific SNOMED codes. Confirmed case information is likely to be identified away from the patient’s general practice and then communicated back to general practice.

Codes related to risk categories for developing complications from COVID-19

There are three SNOMED codes available in GP systems to indicate a patient’s risk category for developing complications from COVID-19:

Where recorded in the GP record, the single most recent instance of the three COVID-19 risk category codes is included in SCR Additional Information. These codes will appear on the SCR under the heading ‘Risks to Patient.’

These codes relate to a separate programme of work that has been undertaken to identify a cohort of patients who may benefit from ‘Shielding’. These patients have been advised to not leave their home and minimise contact with other members of their household and will be offered access to home shielding support. There is a National Shielded Patient List (SPL) which is created and maintained by NHS Digital on behalf of the NHS. The SPL is reviewed regularly and updated to improve accuracy according to the Chief Medical Officer (CMO) criteria.

A group of high risk patients was initially identified from centrally available data and these patient’s then had the code ‘High risk category for developing complication from COVID-19 infection’ added to their GP record. Following this, general practices have reviewed this group to identify those patients who have been recorded as ‘High risk category for developing complication from COVID-19 infection’ but who do not actually meet the CMO criteria. Those patients found not to meet the CMO criteria had an additional code added to indicate either the Moderate or Low risk category.

Data is regularly extracted from GP records and where there are changes to the patients’ latest risk category code either from or to ‘High risk category for developing complication from COVID-19 infection’ this is synchronised to the SPL database.

A flag has been created on SCRa that will identify patients currently on the SPL. However, SCR content reflecting vulnerability to COVID-19 infection complications may not always align with the SPL, due to synchronisation issues and different data sources.

The risk category codes for developing complications from COVID-19 infection may support patient management but should not be used in isolation as an assessment of risk. Patient management decisions should always be made drawing from the widest range of available information sources. These might include the patient and their carers, currently available evidence and information about co-morbidities available from other sources including the rest of the SCR.

Separate guidance is available about how information about patients who are on the SPL is made available in SCRa and SCR 1-Click.

COVID-19 message box in SCRa, SCR 1-Click and SCRa Private Beta

Five of the commonly used codes for suspected and confirmed COVID-19 cases are signposted by a yellow message box when viewing the SCR screen on SCRa and SCR 1-Click and a yellow banner when viewing SCRa Private Beta.

SCRa and SCR 1-Click yellow message box:

Four of these terms relate to whether the patient has a diagnosis of confirmed COVID-19 based on laboratory test results or clinical diagnostic criteria. The fifth term relates to whether the patient has suspected COVID-19, which will include assessments by NHS 111 telephone service.

The message box is intended to draw attention to specific COVID-19 information in the SCR but not to distract from other important information such as allergies and significant past medical history. 

Negative test results, risk category codes and other COVID-19 related information may be present on a patient’s SCR, however the yellow message box will not be displayed to signpost to this information.

Patients will be aware of their test results in advance of their GP being notified. It will take time for the data to flow through to the GP record and the SCR. There may be occasions where the GP record and the SCR are not updated with the COVID-19 results received by individuals, for example, where it was not possible to ascertain the NHS number from the information provided to the test centre.