Involving patients in checking the validity of the NHS shared record: a single practice pilot

Abstract

To assess how involved patients wish to be in the compilation of their NHS core clinical record, and to assess the accuracy of general practitioner (GP) produced summaries. DESIGN, SETTING, METHOD AND PARTICIPANTS: In a Scottish urban practice of 6800 patients we compiled a core clinical summary based on historical paper and electronic records. We invited a 1 in 10 sample of our patients of all ages to request, view and check a copy of their core clinical record. We offered patients the chance to discuss and correct any inaccuracies in their core clinical summary by use of a response form, telephone or meeting. Out of 646 patients, 258 (40% of our sample) responded to the invitation to check their core clinical summary. Of those, 187 (72.5%) of these summaries were accurate according to patients. There were 89 inaccuracies reported by patients. Of these, 42 (47%) were of obvious clinical importance including wrongly entered diagnoses, or missing major morbidity such as an operation, or errors in repeat medication. There were 47 (53%) inaccuracies in lifestyle data (smoking, alcohol history or weight), or dates of illnesses. Only a minority of patients chose to view and offer comment on their core clinical summaries. The majority of summaries were deemed to be accurate but there was a worrying level of omission and inaccuracy, including medication. It might be a better use of time to support doctors and patients working together to construct and check summaries rather than on information technology (IT) and the complex ethical debate surrounding the core clinical Spine.