Recurring concern
Unreliable recording of patients' clinically relevant medical history
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Request correctionFirst reported 28 Jul 2014•Latest report 9 Jul 2025
What this concern includes
Includes failures of patient-assessment controls for capturing clinically relevant medical history or medical conditions, including reliance on verbal-only communication, failure to record negative answers, and absence of alternative or structured methods that would make the information complete and reliable.
Not included
- Excludes failures limited to reviewing, sharing or acting on medical history that was already accurately captured.
- Excludes generic clinical record-keeping deficiencies where medical history capture is not the identified unsafe condition.
- Excludes failures to obtain unrelated information, such as administrative details, unless they directly concern clinically relevant medical history or medical conditions.
- Excludes failures of diagnosis or treatment where the relevant medical history was captured adequately.
- Reports
- 9
- Individual concerns
- 10
- Date range
- 2014–2025
- Stated actions
- 17
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
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Concerns raised2
Failure of the pre-day-surgery assessment system to require questions about patients' haematological family history
Failure of the pre-day-surgery assessment system to record negative answers about patients' own haematological history
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Action
Add family-history prompts, including venous thromboembolism, to the pre-operative assessment form.
Stated by Surrey and Sussex Healthcare NHS Trust -
Action
Add the family-history question to the patient questionnaire through a future questionnaire-service update.
Stated by Surrey and Sussex Healthcare NHS Trust -
Action
Undertake an after-action review to identify how the gap arose and establish learning and remedial actions.
Stated by Surrey and Sussex Healthcare NHS Trust
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Concerns raised1
Failure to elicit callers' existing medical conditions
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
NHS Pathways limits past medical history questions because broader questioning could delay assessment without changing the triage outcome.
Stated by NHS England
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Position
Health advisors are not expected to interpret comprehensive medical records; limited history questions and clinical escalation are considered safer and more effective.
Stated by NHS England
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Concerns raised1
Failure to elicit relevant family medical history
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
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Action
Update the NHS health-check template to record negative family history of ischaemic heart disease.
Stated by Church Lane Surgery -
Action
Expand family-history updates to annual chronic-disease checks, medication reviews, ECG appointments and standardised templates.
Stated by Church Lane Surgery -
Action
Begin updating ischaemic-heart-disease family histories for all patients aged over 25 and inform patients about voluntary updates at registration.
Stated by Church Lane Surgery
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Action
Train staff to collect and accurately record family-history information in the clinical system.
Stated by Church Lane Surgery
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The family history was not disclosed during prior consultations, so it was unavailable for consideration in risk assessment and prescribing.
Stated by Church Lane Surgery
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Concerns raised1
Inadequate questionnaire on the person's medical history
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Action
Establish high-level principles for safe remote consultations and online prescribing with healthcare organisations.
Stated by General Pharmaceutical Council -
Action
Launch a call for evidence on remote consultations and prescribing to assess whether existing guidance remained appropriate for changing practice and technology.
Stated by General Medical Council -
Action
Publish updated prescribing guidance covering remote consultation suitability, information sharing, patient dialogue, and safeguards for controlled or potentially addictive medicines.
Stated by General Medical Council
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Online consultations and prescribing without face-to-face assessment can be safe where appropriate safeguards, history-taking, GP engagement and monitoring exist.
Stated by Care Quality Commission
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Concerns raised1
Inadequate recording and coding of relevant medical history on the active problem list
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Inspections ultimately found no concerns in the areas identified, so there was no basis for enforcement action.
Stated by Care Quality Commission
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Concerns raised1
Unreliable recording of relevant past and current medical conditions
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
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Action
Remind clinical staff in writing to check all relevant SystemOne record sections and use the search function when reviewing previous medical conditions.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust -
Action
Work with NHS England on national resolution of SystemOne read-coding inconsistencies.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust -
Action
Introduce SNOMED CT as the alternative coding system in prison general-practice SystmOne records.
Stated by NHS England
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Action
Support health and justice users during the transition to SNOMED CT by working with NHS Digital and regional commissioners.
Stated by NHS England
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Local trusts cannot alter SystmOne’s national read-coding system because it is outside their control.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust
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Position
National resolution of inconsistent SystmOne read coding is assigned to NHS England.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust
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Concerns raised1
Failure to record medical conditions through a method independent of verbal communication
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Action
Test digital pads for storing patients’ signed confirmation that medical questions were understood and answered accurately.
Stated by Masta Limited -
Action
Produce and finalize a pre-consultation medical-question fact sheet explaining the questions and their importance.
Stated by Masta Limited -
Action
Provide clinics with a laminated copy of the medical questions for patients to review with nurses during risk assessments.
Stated by Masta Limited
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
A patient-completed tick-box questionnaire is considered less effective because last-minute attendance and context-free questions may cause errors.
Stated by Masta Limited
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Concerns raised1
Inadequate preoperative medical history-taking and recording
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to capture important patient history at admission
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026