Developing a unified patient record: a practical guide
International Journal of Integrated Care, 5 July 2004 - ISSN 1568-4156
Book review
Developing a unified patient record: a practical guide
Deb Thompson and Kim Wright
Radcliffe Medical Press, 2003, pp 140,
ISBN 1 85775 9397
Han de Ruiter, Groningen University Medical Centre (GUMC)

This is what we read on the back flap: ‘This comprehensive and practical guide helps professionals and staff within hospitals change the way they collect, store and use clinical information about patients. It illustrates how clinical governance and evidence-based practice can be easily addressed by modernising clinical information practice, to benefit patients and improve staff and service efficiency.’

This is a clear description of what the authors want to carry out with this book. Because it is mainly focussed on the hospital situation, there seems not a direct relationship with integrated care. But one can say: if you do the recording of patient information in the hospital in a good way, it will have a positive effect on the health care facilities outside the hospital (home care, nursing care homes, general practitioner etc.).

This very handsome and readable book is based on the experiences of two well-qualified nurses from the United Kingdom. And for this reason it is written in a practical way; what you see is what you get! The book contains nine chapters. One very positive aspect is the multidisciplinary approach to patient-focused care. All chapters are illustrated with a lot of practical examples and figures.

After a short introductory chapter, one can read in Chapter 2 about the ins and outs of a unified patient record. In Chapter 3, the focus is on the need to base practice on evidence, and the use of care guides as a practical tool to enable this to happen. In Chapters 4 and 5 the authors focus on clinical record keeping and the concept of the electronic patient record, and the ways in which they are inextricably linked.

In Chapter 6 is described some of the characteristics of change. This includes a review of clinical projects resulting in successful change. Also examples are given of strategies and models that can be used in the implementation and subsequent evaluation of the unified patient record (UPR). After a short chapter on frequently asked quuestions Chapter 8 is very practical in its intention. It gives practical advice about carrying out a project, a so-called ‘Toolkit’. In Chapter 9, the last chapter, one can read an extensive example of a UPR. The book ends with a Glossary of terms, advices for further reading and, last but not least, an index.

For those who want to start with a unified patient record, one can read Chapter 8. In this chapter, a toolkit is presented for the development of a UPR. Although the content is written for the situation in the UK, everyone who is interested in this integrated care record can use some of the practical advice from this book.

Finally, the best tip given is: ‘A touch of humour always helps’ (p. 95).