Case study on Summary Care Records and additional information: Dr Mark Spring GP

Dr Mark Spring is a GP at Sandford Surgery in Dorset. He is also the clinical lead for Urgent Care Services, a GP Out of Hours service in the same area. In this case study he explains the value and simplicity of enriching Summary Care Records (SCR) with additional information.

Creating Summary Care Records with additional information is simple and very effective. Enhancements to the SCR mean that a set of additional information from the GP record, in addition to medication, allergies, and adverse reactions, can now be easily added to support the delivery of person centred co-ordinated care. SCRs with additional information include significant medical history and procedures, anticipatory care information, immunisations, end of life care information and communication preferences. Dr Spring comments: 'The enhanced functionality to create SCRs with additional information is simple. The whole process is easy and takes less than a minute to do. Consent from the patient can be gained by GPs, nurses, healthcare support workers or a receptionist. I can be confident that significant information from the patient's record will be instantly available within their SCR. I can record information once and share it easily, which is fantastic!'

SCRs with additional information are especially helpful for clinicians who are treating patients within an urgent and unscheduled care setting. Dr Spring explains why making this information available is so important: 'As an Out-of-Hours GP, I know the importance of making sure essential patient information can be accessed. My patients don't just have problems from nine to five. They need and deserve high quality, informed healthcare whenever it is required. In the past, there has been a lack of information to support patients when they receive care away from their GP practice. Patients feel frustrated at being asked to repeatedly provide the same information and often find it difficult to recall this clearly. Sharing information such as patient preferences or plans for future care supports both me and my colleagues to really understand patients, their circumstances and their choices.'

Dr Spring states: 'Knowing details of a patient's medication and allergies is really useful. However, also knowing the reason for the medication and any significant medical history or diagnoses is quite simply invaluable. This is what the SCR can now provide.' He concludes: 'Creating SCRs with additional information is simple and very effective in supporting clinical management. It helps to make clinical engagement with new and unfamiliar patients safer and is particularly helpful in supporting doctors who are treating the most complex and vulnerable patients.'

Example 1: Using SCR with additional information to help treat an elderly patient out of hours

Dr Spring was asked to triage an elderly patient late on a Friday evening. The patient had been diagnosed with a urine infection and had been prescribed cefradine earlier in the day. The patient was concerned that she may be allergic to the medication. Dr Spring was able to access the patients SCR which highlighted that previous medication had made the patient nauseated and confused, and that she was allergic to penicillin. However, as this was an SCR that included additional information, he was also able to establish that the patient had a complex medical history and had been prescribed cefradine previously, without any apparent ill effect, and was therefore able to successfully reassure the patient to continue with their medication.

Example 2: Using SCR with additional information to provide continuity of care to a new patient

Dr Spring saw a 45 year old man who was new to the practice and presented requesting a prescription for medication he had been taking for hypertension. Despite the patient appearing well, Dr Spring asked for consent to view the patient's SCR. Dr Spring was able to establish that the patient was an ex-combatant with a history of severe depression and had in the past made a serious attempt on his own life. Understanding the patients previous problems helped build an early rapport with the patient leaving the patient impressed with the continuity of care he had received.