A Guide to NHS health records which play an important role in modern healthcare. They have two main functions, which are described as either primary or secondary. The NHS is also currently making some important changes to how it will store and use health records over the next few years.
Primary function of health records
The primary function of healthcare records is to record important clinical information, which may need to be accessed by the healthcare professionals involved in your care.
Information contained in health records includes:
- the treatments you have received,
- whether you have any allergies,
- whether you're currently taking medication,
- whether you have previously had any adverse reactions to certain medications,
- whether you have any chronic (long-lasting) health conditions, such as diabetes or asthma,
- the results of any health tests you have had, such as blood pressure tests,
- any lifestyle information that may be clinically relevant, such as whether you smoke, and
- personal information, such as your age and address.
Secondary function of health records
Health records can be used to improve public health and the services provided by the NHS, such as treatments for cancer or diabetes. Health records can also be used:
- to determine how well a particular hospital or specialist unit is performing,
- to track the spread of, or risk factors for, a particular disease (epidemiology), and
- in clinical research, to determine whether certain treatments are more effective than others.
When health records are used in this way, your personal details are not given to the people who are carrying out the research. Only the relevant clinical data is given, for example the number of people who were admitted to hospital every year due to a heart attack.
Types of health record
Health records take many forms and can be on paper or electronic. Different types of health record include:
- consultation notes, which your GP takes during an appointment,
- hospital admission records, including the reason you were admitted to hospital,
- the treatment you will receive and any other relevant clinical and personal information,
- hospital discharge records, which will include the results of treatment and whether any follow-up appointments or care are required,
- test results,
- photographs, and
- image slides, such as those produced by a magnetic resonance imaging (MRI) or computerised tomography (CT) scanner.
There are strict laws and regulations to ensure that your health records are kept confidential and can only be accessed by health professionals directly involved in your care.
There are a number of different laws that relate to health records. The two most important laws are:
- Data Protection Act (1998), and
- Human Rights Act (1998).
Under the terms of the Data Protection Act (1998), organisations such as the NHS must ensure that any personal information it gathers in the course of its work is:
- only used for the stated purpose of gathering the information (which in this case would be to ensure that you receive a good standard of healthcare), and
- kept secure.
It is a criminal offence to breach the Data Protection Act (1998) and doing so can result in imprisonment.
The Human Rights Act (1998) also states that everyone has the right to have their private life respected. This includes the right to keep your health records confidential.
The NHS is currently making some important changes to how it will store and use health records over the next few years. See the Service description section below for more information.
Changes to the way health records are used and stored
The NHS is planning to change the way it stores and uses health records.
Most health records are stored at the place where a treatment or test was given. For example, your consultation notes will be stored at your GP surgery and your hospital admission record will be stored at your local hospital.
If a healthcare professional in another part of the country, such as a specialist working in a cancer clinic, requires access to these records, they will have to get the information by phone, fax or secure email.
However, this can be very time consuming and mistakes can occur in the transmission of information. More importantly, if a healthcare professional cannot get quick access to relevant health records, patients may be placed at risk.
For example, imagine a situation where a person who lives in London is on holiday in Brighton. One evening, they're involved in a car accident and are knocked unconscious and taken to an accident and emergency (A&E) department. Under the current system of storing health records, it would be difficult for A&E staff to find out whether there are any important factors that need to be considered when treating the person (such as whether they're allergic to certain painkillers) as their GP surgery is likely to be closed.
To overcome these problems, the NHS is introducing summary care records.
Summary care records
A summary care record is an electronic record that is stored at a central location. As the name suggests, the record will not contain detailed information about your medical history, but will only record certain important clinical facts, such as:
- whether you have any health conditions,
- whether you're taking any prescription medication,
- whether you have any allergies, and
- whether you have previously had a bad reaction to any medication.
Access to your summary care record will be strictly controlled. Only NHS staff directly involved in your care who have a special smartcard and access number (like a chip-and-pin credit card) will be able to access the information.
Different levels of information that can be accessed will also be controlled. For example, a hospital receptionist will be able to access your contact information but not your medical history.
The only healthcare professionals with unlimited access to all summary care records will be those who work in A&E. This is because they could potentially need access to the information at any time in the event of an emergency.
Pilot schemes to trial summary care records have been set up in a number of primary care trusts (PCTs). If they're successful, summary care records are expected to be introduced across the NHS by 2012.
Do I have to have a summary care record?
No. You'll be informed by letter when it's time for your local PCT to introduce the scheme. The letter will also contain details about how you can opt out of the scheme. If you opt out, you can rejoin the scheme at any time.
If you want to have a summary care record, you don't have to take any further action. If you don't opt out, you will automatically join the scheme.
Personal electronic health records
The NHS has recently introduced personal electronic health records. These are electronic health records that are entirely under your control. Information that you can add to your personal electronic health records include:
- your weight,
- your blood pressure readings,
- your cholesterol level,
- the amount of alcohol you drink,
- any medication you take, and
- the date and time of any appointments you have.