GPs have been given medico-legal advice about the implications of using the Summary Care Record and uploading information to the Spine.
A series of more than 40 frequently asked questions prepared by NHS Connecting for Health and the Medical Protection Society have been published on the CfH website.
Dr Stephanie Bown, MPS director of policy and communications, said: “The Summary Care Record represents a fundamental reform of the way that patient records are stored and accessed.
"It is understandable that this could feel very challenging and it is of crucial importance that doctors are supported.
"MPS has, therefore, worked with NHS Connecting for Health to provide information and answers to some of the dilemmas doctors will face, in order to help them effectively deal with these changes.”
The advice covers key areas such as the implications of using an SCR which is incorrect, how to handle uploads involving Gillick competent children, and the medico-legal significance of adding additional information to the SCR.
The advice says that if the SCR is inaccurate or out-of-date the responsibility lies with the person who made the record – although a health professional would be expected to be alert to potential inconsistencies.
It says failure to usean NHS smartcard during patient encounters would mean that updated patient information would not be sent to the Spine.
It adds: “This could mean that clinicians using the SCR will not have timely, relevant information about your patient. This could adversely impact on the care your patient receives and they could be put at risk as a result.”
If an SCR is factually incorrect the guidance states that, as with manual records, a health professional is generally entitled to rely on the clinical notes.
However it adds: “Responsibility for an erroneous entry would usually lie with the person who made the entry, unless there was an obvious discrepancy which should have been picked up by anyone reading the record.
"In some circumstances, where the information is of particular importance, and easy to check (for example, a drug allergy), there might be an expectation that the health professional check the position with the patient.”
If practices decide to add additional information to the SCR such as significant medical history it says there is no legal requirement to gain the patient’s explicit consent but that the practice might want to discuss it with the patient before doing so.
The advice adds: “Practices which enrich records without consent should ensure that the material patients have received through the public information programme incorporates the significant medical history elements that could be included.”
Other topics covered in the FAQs include use of the ‘permission to view’ model in different scenarios and a GP practice’s medico-legal position if it decides not to take part in the SCR programme but one of its patients wishes to have an SCR.