Retrieving information from, documenting within and interpreting patients notes are the bane of every clinician's life. Many are unhappy with the current state of patient notes in their hospital. The authors of this small practical book identify what they offer as a potential solution to successful record keeping, the unified patient record. The authors are both nurses by background, one having specialized in practice development and the other with particular expertise in health informatics. They present the context for developing a unified patient record, its potential strengths and importance, and then present a model of such a record. Finally, the authors discuss the practicalities of implementing a unified patient record within an NHS hospital, together with tips for smoothing its passage.
The book starts with a competent description of the many weaknesses of traditional paper notes and the implications for clinical governance. The authors then go on to define the term unified patient record and describe one such model, making liberal use of their own experience implementing a specific project within Weston Area Health NHS Trust. Aspects of the model, such as the Gloucester Patient Profile, are of particular interest. This profile seems to simplify and improve current documentation around patient progress. Similarly, the coverage of strategies for risk assessment and its documentation is of interest, as is the attractive update to the dreaded nursing Kardex. The relationship of the unified patient record to an electronic patient record is examined and a reasonable justification is given for starting with a written version prior to developing an electronic one.
The book contains many illustrations, tables and charts which generally enhance its accessibility. It does contain a plethora of jargon, from SWOT to PESTLE to force field analysis, but perhaps this is a necessary evil.
So who should read this book? The fact that one is tempted to say not me probably says as much about the reviewer as the book. The subject area is certainly not everyone's cup of tea. Moreover, the impression is that it deals more competently with aspects of patients notes other than the medical documentation (although I am sure the authors would take issue with this). For individuals involved in redesigning patient records, including those developing an electronic patient record, I am sure this guide contains enough of relevance to justify both the cost of the book and the time spent reading it.
The author has declared no conflicts of interest.