• Anna L Crucefix, Aaron P L Fleming, Caroline S Lebus, Anne-Marie Slowther, and Zoë Fritz.
• University of Cambridge Clinical School, Cambridge, UK.
• J Eval Clin Pract. 2021 Dec 1; 27 (6): 1235-1242.

Rationale, Aims And ObjectivesSharing aspects of the traditional medical record with patients has been successful in primary and antenatal care, but has not been investigated in the UK inpatient setting. Our aim was to evaluate the impact on patient and clinician experience of providing patients with a written lay summary of their care-plan in the acute care setting.MethodWe carried out a qualitative interview study on two acute medicine wards in an NHS University Teaching Hospital for a 4-week period in 2019. A summary record, designed in response to suggestions from doctors and patients from a previous study, was distributed to patients on the first ward round after admission. Eligible participants included all doctors and nurses working on and all patients and their families attending the acute medical units; patients were excluded if they lacked capacity to consent or were under 18. We interviewed 20 patients, 10 relatives, 10 doctors and 7 nurses.ResultsPatients felt that the summary improved their ability to remember details about their care so they could more accurately and easily update their relatives. They did not feel that the summary induced anxiety. Patient-doctor communication was improved: patients felt empowered to ask more questions and doctors felt that it solidified their plan and encouraged them to avoid medical jargon. Most patients felt the summary included the 'right' amount of information. Healthcare professionals were more concerned about the risk of breaching confidentiality than patients. Doctors felt that providing summaries was time-consuming; there were differing opinions about whether this was a worthwhile investment of time. Clinicians recognized that the traditional medical record has many roles.ConclusionsA summary record could empower patients and improve patient-doctor communication but would require additional clinician and administrative time.© 2021 The Authors. Journal of Evaluation in Clinical Practice published by John Wiley & Sons Ltd.

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