The development of a patient held record and individual plan of care to improve the level of individualized information and support to our patients.

M Higginbotham, C Jones

York Hospital

BACKGROUND: The National Services Framework for Renal Services, Part One: Dialysis and Transplantation was published in January 2004. Standard 1 describes a patient- centred service, where patients should have access to information, advice, education and support to allow them to be full partners in their care. It identifies the need for this information to be tailored to individual needs, and for an agreed care plan to help to foster partnerships between patients and clinicians.

PROBLEM: There is a need to provide written information and a plan of care individual to patients needs.

PURPOSE: To produce a written individual plan of care and patient held record. We can then examine whether this can improve patient education, communication with the patient and within the multi-disciplinary team.

BACKGROUND/DESIGN: We currently provide a general written information booklet ‘Living With Kidney Failure’ to patients with chronic renal disease, approaching end-stage renal failure.

METHOD: A patient held record has now been developed by the renal MDT, providing further written information about the functions of the kidneys, progression of renal disease and the aims of pre-dialysis care. There are sections

for the monitoring of weight, blood pressure and blood chemistry, records of medications, vaccinations, dietetic information; a section for named contacts within the multi-disciplinary renal team, and also written care pathways describing the patient journey to dialysis, transplantation, or conservative management, that can be added to the patient held record according to the needs of the individual.

Fifty patients are now being asked to trial the use of the record. Prior to patients being given the document, they are asked to complete a questionnaire regarding aspects of education, information and communication they currently experience. The questionnaire will be repeated to determine whether or not the patients feel that the patient held record has improved education, information and communication and whether or not the use of the record has enabled the patient to feel more involved with their care

CONCLUSION: The use of this record may improve the level of individualised information and support to our patients, and allow the patients and the renal team to foster greater partnerships in care. If the use of the record can achieve this, then we will have also achieved some of the aims of Standard 1 of the NSF: a patient-centred service.