Electronic health records: guidance and policy

Electronic health records (EHRs) are digital records containing information about a patient’s health, care and medicines.

Access to relevant information can help pharmacy teams make safer clinical decisions, deliver NHS services more effectively and provide more joined-up care.

Community pharmacy is becoming increasingly connected with the wider NHS. Record systems, structured clinical messaging and NHS digital services are helping information move securely between pharmacies, general practice, hospitals and other care settings.

This page explains the role of electronic health records in community pharmacy and highlights current developments.

What pharmacy teams need to know

Community pharmacy teams may use several NHS record services and information-sharing tools.

These can help authorised pharmacy professionals:

• view information relevant to a patient’s care;
• support clinical decision-making;
• reduce the need for patients to repeat information;
• improve medicines optimisation; and
• share information with other healthcare professionals where appropriate.

The information available, and the way it is accessed, varies depending on the NHS service, local arrangements and the capabilities of individual IT systems.

Pharmacy owners should ensure that authorised team members have access to the systems needed to support the services they provide and understand how those systems should be used.

Current record systems

Electronic health records are not a single system.

A range of national and local services help authorised healthcare professionals access and share information safely.

Community pharmacy teams may interact with:

• the Summary Care Record (SCR);
• the National Care Records Service (NCRS);
• Shared Care Records (ShCRs);
• GP Connect;
• the Single Patient Record programme; and
• the NHS App.

Each service has a different purpose and may contain different information. Some services support viewing information, while others support the sharing of information between healthcare settings.

Using records to support patient care

Access to relevant patient information can support:

• Pharmacy First consultations;
• contraception services;
• blood pressure services;
• vaccination services;
• medicines optimisation;
• prescribing-based services;
• urgent care support; and
• management of long-term conditions.

As community pharmacy takes on a greater clinical role, timely access to appropriate information is becoming increasingly important for patient safety and continuity of care.

In some services, information recorded by pharmacy teams can also be shared with general practice and other healthcare professionals using structured digital messaging and interoperability standards.

Accessing records appropriately

Patient records should only be accessed where there is a clear and legitimate work-related reason.

Access must be:

• relevant to the care being provided;
• necessary for the task being undertaken;
• appropriate to the user’s role; and
• consistent with information governance requirements.

Pharmacy owners should ensure that team members:

• complete required information governance and data security training;
• understand their responsibilities when accessing records;
• know how to report information governance incidents; and
• recognise that record access is routinely audited.

Patients rightly expect their information to be handled securely and appropriately.

For detailed guidance, see NHS England’s guidance on lawful and unlawful access to health and care records.

Making clinical records appropriately

Clinical records and consultation documentation

As community pharmacy services become increasingly clinical, effective documentation can help support safe, efficient and joined-up care.

Clinical records can help pharmacy professionals record the care provided, support continuity of care and share relevant information with other healthcare professionals where appropriate. They may also help demonstrate service activity and outcomes.

The NHS is continuing to develop shared records and wider interoperability between healthcare settings. As these arrangements expand, the value of timely and accurate information sharing is likely to grow further. This is expected to support more joined-up care across community pharmacy, general practice and other parts of the NHS.

Documenting consultations

NHS clinical service specifications include requirements relating to record keeping and the submission of consultation information.

Where possible, pharmacy professionals may find it helpful to create consultation records during or shortly after the patient interaction. This can help support:

• Accurate recording of information;
• Continuity of care;
• Efficient communication with other healthcare professionals; and
• Future reference where follow-up care is required.

Pharmacy owners and pharmacy professionals should ensure that they are familiar with any service-specific, employer, professional or regulatory requirements that apply to their practice.

Using pharmacy IT systems

Many pharmacy IT systems include features designed to support both consultation recording and clinical decision making.

Using these tools may help pharmacy professionals to:

• Access relevant patient information;
• Record clinical activity efficiently;
• Reduce duplicate data entry; and
• Support appropriate information sharing across care settings.

The Community Pharmacy IT Group (CP ITG) supports improvements to interoperability and electronic records so that information can flow more effectively between community pharmacy and the wider NHS, while helping to minimise unnecessary administrative burden for pharmacy teams.

Learning and guidance

Pharmacy professionals who wish to refresh their knowledge of clinical documentation may find the Centre for Pharmacy Postgraduate Education (CPPE) Documenting in patient clinical records learning programme useful.

The programme covers:

• Legal and professional requirements relating to patient records;
• What information may be useful to include in clinical records;
• Approaches to structuring clinical records; and
• Recording consultations and clinical interventions clearly and accurately.

Record keeping guidance

Further information is available from:

• High-quality patient records (NHS guidance)
  Guidance on creating accurate, useful and patient-centred healthcare records.
• Clinical documentation guidance (RCPharm)
  Practical guidance on when, where and how to make clinical records, including examples.
• CPPE: Documenting in patient clinical records
  E-learning programme for pharmacy professionals.

Information sharing across the NHS

The NHS continues to improve how information is shared between healthcare settings.

This includes enabling information to move more easily between community pharmacy, general practice, NHS services and other care settings.

Better information sharing can help:

• reduce duplication;
• improve patient safety;
• support integrated care;
• reduce administrative burden; and
• improve communication between healthcare professionals.

Community Pharmacy England supports the use of open standards and interoperable systems that allow information to move securely and appropriately between healthcare settings.

This aligns with long-term NHS ambitions for more joined-up care and the increasing integration of community pharmacy within neighbourhood health services. The NHS is also developing the Single Patient Record, which aims to bring health information together more effectively across care settings.

Future developments

Several NHS programmes are expected to increase the role of electronic health records within community pharmacy.

These include:

• further development of the Single Patient Record;
• expansion of pharmacy prescribing-based services;
• improved interoperability between NHS systems;
• wider use of structured clinical messaging;
• increased NHS App integration; and
• greater sharing of information across primary care and neighbourhood health services.

Community Pharmacy England continues to work with NHS England, the Department of Health and Social Care, IT system suppliers and other stakeholders to ensure pharmacy requirements are reflected within future digital developments.

Community Pharmacy England’s position

Community Pharmacy England supports:

• appropriate role-based access to information needed to provide patient care;
• secure and effective sharing of healthcare information;
• open standards and interoperability;
• pharmacy system choice;
• digital inclusion;
• systems that reduce unnecessary administrative burden;
• robust information governance and patient confidentiality;
• user-centred design; and
• meaningful pharmacy engagement in digital transformation.

Access to the right information, at the right time, can help pharmacy teams provide safer care and support the increasing clinical role of community pharmacy within the NHS.

Record systems at a glance

Related pages

• Summary Care Record (SCR)
• National Care Records Service (NCRS)
• Shared Care Records (ShCRs)
• GP Connect
• Single Patient Record
• NHS App
• Data security
• Digital and Technology hub

Return to the Pharmacy IT hub

For more information on this topic please email it@cpe.org.uk