<!-- Derived Markdown alternate of foundations/records-and-purposes.md; canonical repository sources and registered evidence retain authority. -->


# Records and their purposes

A clinical record is an account of care. Before choosing software, establish what each account must preserve and how it contributes to care over time.

## Primary and specialist source records

Start with the **general practitioner (GP) record**. It records care delivered by the GP team and incorporates relevant information received from other services. NHS England's Records Management Code of Practice calls it the **primary record of care (PRC)**. It follows the patient between GP practices, and most other services must inform the GP through discharge notes or clinical correspondence. [SRC-004](https://copper-tiger.pages.dev/sources/index.md#src-004) [SRC-125](https://copper-tiger.pages.dev/sources/index.md#src-125)

A **source record** is the originating account of the care a service provides: its assessments, decisions, treatment and follow-up. **Source** describes where that account originates; **primary** describes the GP record's continuing role across services and episodes. **The GP record is both a source record and the PRC.** These are overlapping roles. [SRC-004](https://copper-tiger.pages.dev/sources/index.md#src-004) [SRC-005](https://copper-tiger.pages.dev/sources/index.md#src-005)

**Specialist source record** is this wiki's shorthand for the detailed, service-specific account. It includes intermediate or community care and hospital care; it is not limited to a consultant's notes or one encounter. The GP record has this service-specific source role too, with the additional PRC role. This is explanatory vocabulary for the proposed model, rather than a separate NHS record classification. [SRC-003](https://copper-tiger.pages.dev/sources/index.md#src-003)

The examples below distinguish the roles, without prescribing separate applications or files:

| Record | What originates here | Relationship to the PRC |
|---|---|---|
| **GP record** | The GP team's consultations, assessments, prescribing and care decisions. | **Source record and PRC:** combines the practice's own account with relevant information received from other services. |
| **Intermediate or community care record** | For example, a rehabilitation, community nursing or community mental-health team's assessments, care plan, interventions and progress. | **Specialist source record:** preserves that service's account and contributes relevant updates to the PRC. It does not become the PRC. |
| **Hospital record** | For example, inpatient and outpatient assessments, investigations, procedures, treatment and discharge planning. | **Specialist source record:** preserves the hospital's account and contributes relevant findings and plans to the PRC. It does not become the PRC. |

**Primary** does not mean that the GP record contains every detail or replaces the originating record. Each service's account remains evidence of its own care. These services can work alongside one another; they are not mandatory stages in a GP-to-hospital sequence. The [systems page](https://copper-tiger.pages.dev/foundations/systems-and-capabilities/index.md) explains how one application can support several record roles. [SRC-003](https://copper-tiger.pages.dev/sources/index.md#src-003) [SRC-004](https://copper-tiger.pages.dev/sources/index.md#src-004)

## How source records contribute to continuing care

Information moves in both directions. Recognised clinical sharing patterns connect these records:

```mermaid
flowchart TB
  accTitle: GP, community and hospital source records and their clinical communications
  accDescr: The GP record is a source record and also the primary record of care, or PRC. Community and hospital records are specialist source records. Referrals and relevant history go from the GP to each service. Community reports and care updates, and hospital letters, results and summaries, contribute relevant information to the GP record. The arrows show selected clinical communications, not automatic interfaces or transfer of responsibility.
  gpRecord["GP record: source record + PRC"]
  communityRecord["Community record: specialist source"]
  hospitalRecord["Hospital record: specialist source"]
  gpRecord -->|"Referral + history"| communityRecord
  communityRecord -->|"Reports + updates"| gpRecord
  gpRecord -->|"Referral + history"| hospitalRecord
  hospitalRecord -->|"Letters, results, summaries"| gpRecord
```

**Read the diagram:** community includes intermediate care. Each service retains its source account; relevant communications contribute to the GP record's additional PRC role. The arrows show selected clinical communications, not automatic system interfaces. Community and hospital services can also communicate directly. Shared viewing does not necessarily update the PRC, and receiving information does not itself transfer responsibility for follow-up. [SRC-004](https://copper-tiger.pages.dev/sources/index.md#src-004) [SRC-005](https://copper-tiger.pages.dev/sources/index.md#src-005) [SRC-020](https://copper-tiger.pages.dev/sources/index.md#src-020) [SRC-022](https://copper-tiger.pages.dev/sources/index.md#src-022)

- **Referral and relevant history:** the GP sends the clinical question and background needed by a receiving service. That service records its own assessment and decisions. The Clinical Referral Information Standard defines content for GP referrals to hospital consultants and other outpatient professionals. [SRC-060](https://copper-tiger.pages.dev/sources/index.md#src-060)
- **Reports, care updates and discharge summaries:** the receiving service communicates relevant findings, treatment and plans to the GP. Community examples include assessment reports, care-plan changes, progress updates and discharge from a service. Hospital examples include outpatient letters and inpatient discharge summaries. Diagnostic reports convey test findings. These communications contribute to the PRC while the service retains its source account. The exact content and route depend on the pathway; there is no single community correspondence profile established by this research. [SRC-061](https://copper-tiger.pages.dev/sources/index.md#src-061) [SRC-062](https://copper-tiger.pages.dev/sources/index.md#src-062) [SRC-020](https://copper-tiger.pages.dev/sources/index.md#src-020)
- **Shared access:** an authorised clinician consults information from another source record, for example through a shared care view. Viewing it does not necessarily add it to the GP record. [Summaries and shared views](#summaries-and-shared-views) explains that distinction. [SRC-004](https://copper-tiger.pages.dev/sources/index.md#src-004) [SRC-022](https://copper-tiger.pages.dev/sources/index.md#src-022)

Sending relevant information to the GP is different from transferring the full GP record when the patient changes practice. It is also different from handing over responsibility for an action. The [information and work page](https://copper-tiger.pages.dev/foundations/information-and-work/index.md) develops these distinctions; the [correspondence catalogue](https://copper-tiger.pages.dev/clinical-correspondence/index.md#correspondence-families) identifies the recognised communication types and their standards.

## Longitudinal history: connecting care over time

**Longitudinal** means extending over time. GP, community and hospital records can all be longitudinal within their scope and involve several professions. Duration and breadth alone do not give a record the PRC role. The PRC connects the continuing GP history with relevant contributions from other services.

The project's **lifelong primary record** is an objective for all patients receiving Defence healthcare, including Armed Forces and civilian patients. The proposed approach maintains the PRC in line with applicable NHS conventions and standards. This supports continuity and record transfer from and to NHS general practice when Defence care arrangements begin and end. Relevant care within and outside Defence belongs within that continuing history. The objective needs more than retained older entries: relevant new reports, their origin and unfinished work must remain usable. [SRC-001](https://copper-tiger.pages.dev/sources/index.md#src-001) [SRC-220](https://copper-tiger.pages.dev/sources/index.md#src-220)

For our patient, changing GP practice should preserve the useful continuing history. It must also leave any pending test visible to those responsible for follow-up. The [information and work page](https://copper-tiger.pages.dev/foundations/information-and-work/index.md) explains why transferring a record does not itself transfer that responsibility.

## Summaries and shared views

A **summary** selects information for a stated purpose. In the proposed model, a specialist report communicates relevant findings and follow-up without reproducing every source entry. Its usefulness depends on what the recipient needs to understand and do. [SRC-003](https://copper-tiger.pages.dev/sources/index.md#src-003)

A **shared care record** brings information from contributing records into shared use. A **shared care view** is the presentation through which an authorised user consults that information. Viewing a shared record and incorporating information into the PRC are separate actions. [SRC-004](https://copper-tiger.pages.dev/sources/index.md#src-004) [SRC-022](https://copper-tiger.pages.dev/sources/index.md#src-022)

A shared view does not determine the storage arrangement. The Records Management Code distinguishes merged records, pooled but separate records, and access to records retained by their originating organisations. It also requires attention to what information was available when a decision was made. [SRC-004](https://copper-tiger.pages.dev/sources/index.md#src-004)

The named NHS **Summary Care Record (SCR)** is a particular summary service, not a generic term for every summary or shared view. Its specific requirements are linked from the [GP record capability reference](https://copper-tiger.pages.dev/gp-it-lot-1/index.md). [SRC-125](https://copper-tiger.pages.dev/sources/index.md#src-125)

## The DShCR alongside the continuing PRC

**Proposed direction.** The **Defence Shared Care Record (DShCR)** would provide a comprehensive, primarily read-only overview across multiple contributing clinical source systems and relevant supporting tools. Authorised users should be able to consult complete contributing clinical records through that one view, including fuller detail beyond PRC summaries. Relevant care progress and outstanding work also belong in the overview in principle; the exact content remains to be defined. [SRC-212](https://copper-tiger.pages.dev/sources/index.md#src-212) [SRC-220](https://copper-tiger.pages.dev/sources/index.md#src-220)

The proposed view is **contiguous and longitudinal**: contiguous means a connected presentation across sources; longitudinal means that it connects information over time. These describe the experience sought, not a single database or a claim that gaps have been removed. [SRC-220](https://copper-tiger.pages.dev/sources/index.md#src-220)

The roles complement one another:

| Role | What it preserves or presents | Relationship to the other records |
|---|---|---|
| **Source record** | The originating clinical account, with its author, context and corrections. | Supplies relevant information to other records; the originating service maintains its entries and corrections. |
| **Continuing PRC** | The GP history and appropriate contributions from other services across episodes and changes of provider. | Receives correspondence and other contributions under applicable NHS conventions and standards. It need not duplicate every specialist entry. |
| **DShCR overview** | A connected history across clinical source records and supporting tools, with access to complete contributing records where permitted and available. | Helps authorised users consult fuller detail within the overall Defence healthcare picture. Source systems retain their originating accounts, authorship and corrections. |

For example, an appropriately authorised Defence GP could consult a full mental-health assessment through the DShCR for occupational primary care and risk management. The PRC would receive the appropriate clinical correspondence or summary. Applicable NHS conventions and standards govern that contribution; this proposal creates no blanket exclusion of mental-health information from the PRC. Exact content requirements and permissions need confirmation. [SRC-212](https://copper-tiger.pages.dev/sources/index.md#src-212)

**Comprehensive** describes the intended coverage. It does not mean every source is connected, every entry is current, or every user can see all content. Access to complete contributing records remains subject to availability, coverage and permissions. The overview must show origin, currency and relevant gaps; source corrections must reach recipients through agreed sharing arrangements. [SRC-212](https://copper-tiger.pages.dev/sources/index.md#src-212) [SRC-220](https://copper-tiger.pages.dev/sources/index.md#src-220)

**Open design questions.** The overview could retrieve information from sources, retain controlled copies, or combine both approaches. Business continuity planning (BCP) should explore retained access, consultation capture and later reconciliation. Forms could add capture alongside the overview; their source-record and correction responsibilities remain to be determined. The [systems page](https://copper-tiger.pages.dev/foundations/systems-and-capabilities/index.md) explains these functions; the [information and work page](https://copper-tiger.pages.dev/foundations/information-and-work/index.md#patient-contributions-and-continuity-options) introduces continuity and return flows. [SRC-212](https://copper-tiger.pages.dev/sources/index.md#src-212) [SRC-220](https://copper-tiger.pages.dev/sources/index.md#src-220)

Previous: [How the concepts fit together](https://copper-tiger.pages.dev/foundations/index.md). Next: [Systems and capabilities](https://copper-tiger.pages.dev/foundations/systems-and-capabilities/index.md).