Patient Information Record system - Basingstoke and North Hampshire NHS Foundation Trust

The Patient Information Record is one hospital’s response to the problems involved in obtaining (and retaining) important patient information, safely and efficiently.

As is often the case, all admissions and assessments on each patient were being carried out on different wards, using different paperwork. This was potentially:

• Frustrating for patients and time-consuming and expensive for the hospital, as much of the information-gathering was duplicated.
• Inefficient from a nursing and medical viewpoint, as specific records / observations were not necessarily easy to locate within a patient’s notes.
• Dangerous and compromised patient safety, as single pieces of paper could easily get misfiled or detached from the patient’s record.

The Solution was simply to combine all admission and assessment information into one booklet – The Patient Information Record. The creation of the Nurse and Learning Environment Lead within the Training and Development Department of Basingstoke and North Hampshire NHS Foundation Trust, the Patient Information Record includes:

• The patient’s personal details
• Admission and assessment record
• Nursing assessment
• Discharge assessment
• Falls risk assessment tool
• Moving and handling assessment
• Braden scale assessment
• Malnutrition assessment
• Thrombosis risk assessment
• Patient take home pack.

This approach to patient records has a range of benefits for both patients and the NHS. It

• Reduces the need to keep asking patients the same questions
• Reduces the cost of information-gathering
• Delivers a higher level of patient safety as all admission and assessment paperwork is kept together
• Makes it easier for nursing and medical staff to find the information they need quickly (because every piece of information has it’s allotted place within the booklet)
• Reduces the risk of transcription errors as nursing staff no longer need to copy information from one source to another
• Reduces the likelihood of paperwork being misfiled or lost.

For further information, please e-mail patientsafety@nisehub.co.uk