A unitary patient record improves admission documentation in a medical assessment unit in a major teaching hospital.

Abstract

Objective: To ascertain the impact of the introduction of a unitary patient record (UPR) on clerking documentation of emergency medical admissions.

Design: Retrospective casenote audit.

Subjects and setting: Random sample of 100 unselected admissions to the medical assessment unit of a major teaching hospital, comprising two groups pre- and post-introduction of the UPR.

Results: Statistically significant improvements in the documentation of several items were achieved; function before episode, ethnic origin, chest pain, breathlessness, ankle oedema, cough, bowel habit and locomotor symptoms and recording of blood pressure and peripheral pulses. There were trends towards improvement in other areas and there were no areas in which the UPR performed less well than standard documentation.

Conclusions: Introduction of the UPR represents the successful application of multidisciplinary principles to over 10,000 acute general medical admissions. It has improved some, but not all, aspects of documentation. Revision of the design of the UPR should lead to further progress, as part of an ongoing process of development and re-audit.