Records in Mental Health Services in England
Over the last 10 years or so, most hospitals and GPs in the UK
have started to use electronic notes, or health records. These are
gradually replacing the old paper notes and are generally called
Electronic Patient Records – or EPRs. These changes are also
happening in mental health services.
There are a number of different software
systems being used. Some have been commercially-produced, others
have been developed by mental health trusts themselves. They all
have the same aim – to provide safe, effective electronic
In this leaflet we look at some common concerns
about this new way of keeping medical records and the Summary Care
Record project that has started in England. There are different
processes in Wales, Scotland and Northern Ireland.
Health Records – and making them
What are health records for?
Doctors, nurses and other health workers all
keep records - also called “notes” or, occasionally, “charts”. In
these they record your medical and social problems and any care
you’ve had. This is so that they, and you, can make good decisions
about your health and care.
How many sets of health records do I
You may have several. Different healthcare
organisations keep separate records. So, each of us will have a
number healthcare records, depending on which services we’ve used.
For example, there could be a record with your GP, one with a
mental health service and another with your local A&E
department or general hospital. These records are currently not
electronically linked, except in a limited way via the Summary Care
Record (see below).
What information is in my health records (paper or
- Any diagnoses and the details of any health
problems you have.
- The treatments you have had.
- How these treatments have helped – or not.
- Any allergies you have – to medications or
- Any medication you are taking – or have taken
in the past.
- Any bad effects you have had from
- The results of any health tests, such as blood
pressure tests, blood tests, X-rays.
- How much alcohol you drink.
- If you use any street drugs.
- Personal information - your age, address,
- Information from other people - hospital
letters, A&E attendances, relatives, carers, insurance
So – why change from paper to electronic
Electronic records are more secure than paper records. Paper
records are sometimes lost and could be (and, often were) destroyed
in floods, fires etc.
Electronic records generally take more time
for health professionals to complete, but they can make it much
easier to find information. They are very clearly indexed, so a
particular record can usually be found in a few seconds.
Health professionals within an organisation
all write in your electronic record. They can see what their
colleagues have written even if they do not work in the same unit.
This means that they can keep up to date with your care more easily
than if records are held on paper.
Electronic records are always available. A
health professional does not need to wait for them to be found and
brought to them when are needed. Paper records can be particularly
hard to locate at night or at the weekend.
Records are also kept so that healthcare
professionals in different organisations can communicate quickly
and clearly with each other. But information held in paper records
has to be passed from one place to another using letters, ‘phone
calls, faxes and emails. This causes delays, particularly at night
or at weekends. At the moment it is not always easy to transfer an
electronic record (or even view it) between different sites or
organisations. However, in the future, these records should be
Electronic systems also create the potential
for you to see your records directly, in the same sort of way that
you may be looking at your bank account over the Internet now. The
‘Five Year Forward View’ (see below) suggests this kind of direct
access, but how it will be done is not yet worked out.
What will happen to my health information currently
held in paper notes?
Some will be transferred directly over to the
EPR system. Some may be scanned in to an electronic storage system
and the paper records then securely destroyed. Some paper notes
will be stored safely in an archive.
How is my Electronic Patient Record stored?
Your information will be stored on “server”
computers which should be connected to a backup system on a
different site. So, if there is a problem such as a fire in one
location, your information will still be safe.
How long will my record be kept?
The same rules apply for electronic records as
for paper records. They should be kept for:
20 years from the date of last contact with
the service, or for 8 years after a patient has died.
Child and adolescent
Until the person's
What if I move or need treatment
Hospitals and GPs don't all use the same EPR system. They may be
able to transfer your records electronically from one to another,
but that depends on the systems they use. If electronic transfer is
not possible, your records can be printed out and sent as a paper
record. You don’t need to take any action.
Even if your whole record can’t be transferred
electronically, it may be possible to transfer certain parts of it,
such as digital X-rays and scans. You may be able to keep your own
copies of these so you can use them if you need unplanned treatment
on holiday. This varies from unit to unit.
Is my information safe?
We worry about:
- Hackers destroying or changing our
- Computer systems breaking down and losing or
- Unauthorised staff looking at records when
they have no business to be doing so.
- Information leaking out.
However, so far, there have been no major
losses of NHS data from EPRs.
According to the Data Protection Act 1988,
"Appropriate technical and organisational measures shall be taken
against unauthorised or unlawful processing of personal data and
against accidental loss or destruction of, or damage to, personal
data." This applies to health records, and so do a number of other
guidelines about how personal data should be stored by the NHS.
These make it hard for data to be illegally accessed by hacking and
unlikely that it will be lost due to a technical failure.
Who can see the Electronic Patient Record about my mental
Only the staff in the hospital or trust who
are directly involved in looking after you.
- Use a secure password that they change
- Only see the information they need to do
- Have their details recorded every time they
use the system.
- Have regular training in the proper use of
information and how to keep it secure.
Your GP can't see your hospital record.
Some other organisations involved in your
care, such as social services, may be able to see some of your
electronic health records. If that is the case, you should be told
that this may happen.
Commercial organisations can't access your EPR
EPR systems keep a record of anyone who looks
at, changes or enters a piece of information on the system. So, if
someone does look at your records when they should not, it will be
recorded and an alert will be issued. Their employer can then take
it up as a disciplinary matter.
Can I see my Electronic Patient Record?
At the moment, it’s not possible in most
places to view any part of your record online. That may be possible
soon, though. You can ask to see your record – even if you are
under 16. Just ask your doctor or nurse. They can show you your
record if it’s appropriate. They will be logged in to their
computer and will show you your record on the screen. You don’t
need to own or be able to operate a computer to see your records in
If, instead of just looking at your records in
the presence of a member of staff, you want to officially request a
copy of your records, you have to write to the local Data
Protection Office. If you do this, the law (the Data Protection Act
1998) says that you may be charged a fee – a maximum of £50 if you
are asking for paper copies of notes.
The NHS, by law, can refuse your request to
see some of your information – but only if, to do so, it might be
harmful to yourself or another person.
If you also want to see the records about you
held by another organisation, you will need to make a separate
request to them.
What if I can't understand what is written in my records?
You can go through any notes that aren't clear with one of your
care team or a mental health advocate.
Can I change - or comment on - information in my
Electronic Patient Record?
If you think that any information is wrong,
start by telling your doctor or anyone else who is looking after
you. They have a responsibility to keep your information up to date
If you don't agree with an opinion or an
assessment, your disagreement can be written as part of the
Can I add information to my Electronic Patient
Yes – you can ask a member of staff to add
information to the record for you.
Can I stop information being put into my Electronic Patient
Only if it is inaccurate. Staff have to record accurate
information about your treatment. Without it, medical or
mental health care cannot be given safely and effectively.
Can I opt-out of having a local Electronic Patient Record?
This is unclear at the moment. Legally you might have the right
not to have your information stored in an EPR. But, healthcare
staff have a duty to keep records about the care they provide. In
many places, there is now no paper record system and the Electronic
Patient Record is the only way of keeping information about your
care and treatment.
Are the records of different organisations joined up?
Not yet – but this will start to happen soon. That is one of the
advantages of electronic record systems. At the moment, your GP
can't see your mental health record, and the mental health team
can't see your GP record. The Summary Care Record (see below) is a
first step towards better information sharing.
How can Electronic Patient Records help healthcare staff to
Any hospital staff who are directly involved
with your treatment can share important information quickly. This
could be your diagnoses, test results, or your current medication.
This can give an accurate picture of your medical history to staff,
even if they do not know you very well.
If hospital staff can see your information
more quickly, they can give you better care. For example, it is
easier to decide safely what medicine to give you if they know:
- What you are already taking.
- Which medication has worked well in the past.
- What dose of medication suits you.
- Any bad reactions to a medicine you’ve had in the past.
You should also not have to repeat your story
over and over again to different doctors and nurses.
Can Electronic Patient Records help me to look after
Some systems are now being developed that can
let you see your own medical notes – or, at least, parts of them.
These can be linked to information about your condition, or the
medication you are taking. So, you can be more involved in your
There are now also phone apps and equipment
that you can use at home. You can track your weight, how much you
drink, your blood pressure and how much exercise you are taking.
These can all help you to take more control of your health and, in
the future, could link directly to your electronic health
What are my rights?
- The health service must keep your records safe and
confidential. This is covered by the NHS Care Record Guarantee and
The Data Protection Act 1998.
- You have a right to see your health records.
- Every trust has a “Caldicott Guardian”. Their
job is to protect your confidentiality. You can contact them
directly if you have any worries.
Current developments– The Summary Care
Record (SCR) (England only)
Today, separate records are kept in all the
places where you receive care. Health records from these places can
usually only be shared by letter, email, fax or phone. At times,
this can slow down treatment and make it hard to get
The aim of the Summary Care Record (SCR) is to
create a copy of important information from your GP health record.
This will be kept in a central, national database which can be used
by any healthcare professional in the country. This means that a
doctor can easily see your records if you are staying in another
part of the country and need medical care.
The Summary Care Record does not contain
detailed information about your medical history. It has information
you might need for urgent treatment, such as your:
- Prescription medication.
- Bad reactions to any medication.
You may want to add other details about your
healthcare to the Summary Care Record. Ask your GP if you want to
You can choose - or refuse - to have a Summary
Care Record. If you would like one, you don't need to do anything -
it will happen automatically. About 95% of the population of
England is currently covered by the project, so you probably have a
Summary Care Record already. A letter was sent to every home some
time ago, describing the SCR and how to opt out if you want to. If
you did not opt out then, you can still do so now. If you do opt
out, you can re-join the SCR scheme at any time.
NHS staff can only see your summary care
record if they are directly involved in your care
and have an NHS Smartcard with a chip and passcode
(like a bank card and PIN). They will only see the information they
need to do their job. Their details will be recorded whenever
they access your data (audit trail).
They have to ask your permission every time
they look at your Summary Care Record. If they cannot ask you, for
example if you are unconscious, they will still be able to use your
Summary care Record, but will have to record in your notes that
they have done so.
The Summary Care Record is designed to improve
your individual care. It is completely separate from a project
called “Care.Data”. This may, in the future, use health information
in various forms of research. Agreeing to have a Summary Care
Record does not mean that your information will be used in the
The ‘Five Year Forward View’ for the NHS was
published on 23rd October 2014 by several organisations
involved with the development and quality of health and care
It suggests that, within five years, you will
- To see your medical and care records
- To write information into your records.
- To share your records with your family or
Where can I find out more?
This leaflet was produced by the Royal College of
Psychiatrists' Informatics Committee, with special
contributions from Laurie Beed and Seb Pringle, members of the
RCPsych Carers and Service User Forums, and the Public
Engagement Editorial Board.
Series editor: Dr Philip Timms
Authors: Dr Mike Robson and Dr Philip
This leaflet reflects the best available evidence at the time
© August 2015. Due for review: August 2018. Royal
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