Ideal for clinical staff interpreting patient notes

What was it like?

This is a quick reference guide to interpreting patients notes. Well set out and not only quick but easy to read also. The authors have taken the strain out of what can be a difficult job in extracting information from the notes but also understanding what is to be extracted. It forms the basics of what is in a patient’s set of notes which is good if we can get the basics right everything else can fall into place. This highlights what good looks like.

What were the highlights?

This is written by academics in the UK for UK readers. Although this looks simple and easy (great for the reader) this has taken a great deal of research and thought to produce this. The section on medical abbreviations was useful and personally as although I interpret notes regularly there was abbreviations I had not come across before. Terminology I take for granted – I heard myself say now I understand.

The layout of the book was pleasing on the eye and each section with a heading in bold so the reader is not trawling through and unable to find vital information.

Strengths & weaknesses:

Strengths – this is easy to pick up and follow and the reader could have this book at hand if reviewing a set of notes as a guide. This edition has been updated to include important aspects such as sepsis. And changes to the reporting of cardiac troponins.

Weaknesses – yes it could be argued that the reader could just use Google or Wikipedia but for the reader who is unsure. This is researched based by academics for the UK rather than the world wide web which has its flaws- and if you are reviewing notes – there is a patient at the centre of this so accuracy is paramount.
This is mainly for readers who are working in secondary care due to having access to patient notes, but primary care staff would benefit as this gives a basic understanding, and at some point, this looks like this may include primary care also in a future edition.

Who should read it?

Staff who are undertaking medical reviews of notes, writing serious incident reports, 7 day service audits obtaining concise information in glossaries aimed for the patient and relatives (rather than looking up Wikipedia), staff who are undertaking audits and harm reviews. As patient notes are often combined this is a quick guide for therapies and other staff who input into patients notes.