The Art of Gathering Medical Histories: Limitations and Pitfalls
In the high-stress environment of the emergency department, obtaining an accurate medical history is a critical part of providing efficient and effective care. However, the collection of accurate patient medical histories can often be a daunting challenge. Time limitations, communication barriers, and documentation inconsistencies can lead to significant limitations and pitfalls in medical history-taking.
1. Medical History Taking is Far From Perfect
Collecting a patient's history is a fundamental aspect of emergency care, with critical implications for patient safety. A study by Mazer et al. focused on medication history, revealing that history-taking in the emergency department (ED) triage often falls short. This prospective survey of adult ED patients found significant discrepancies between the medications listed during triage and those patients were taking. Discontinued medications, omitted medications, and nonprescription medications not listed in the electronic medical record were among the inaccuracies identified, affecting 37% of patients.
2. Variability in Gathering Patient Information
The approach to collecting patient information can exhibit substantial variability, driven by factors such as time constraints, differing levels of experience, and potential biases. In cases involving symptoms like chest pain, comprehensive information gathering is crucial for devising accurate diagnostic and treatment strategies. An investigation involving 332 patients revealed that the patients' demographic characteristics played a significant role in shaping the questions posed by emergency physicians during the history-taking process. Factors such as a patient's age, gender, race, and language preference resulted in variations in the aspects covered during the information-gathering process. These disparities may point to potential cultural biases, influencing the identification of risks and, consequently, treatment decisions. The implementation of a standardized approach to information collection, particularly in cases requiring extensive data, holds the potential for significant enhancements.
3. Discrepancies Between Electronic Documentation and Real-World Practice
The widespread adoption of electronic health records (EHR) has introduced a new set of challenges regarding the accuracy of physician documentation. A study conducted across two academic medical centers unveiled notable inconsistencies between the information recorded in electronic documentation and real-time observations conducted by trained observers. These disparities cast doubt on the reliability of physician actions as depicted in EHRs. However, it's essential to acknowledge that the workload and documentation burden associated with EHRs can be overwhelming, particularly when instantaneous documentation isn't feasible. This can impose a cognitive load on healthcare providers. An effective solution may involve supplementing EHR documentation with direct data collection from patients, ultimately enhancing the accuracy of medical records.
4. The Role of Patient Self-administered Medical History
Traditional patient history-taking during encounters faces numerous challenges, including patient inconsistencies, fear, interruptions, and potential physician bias. In the emergency department setting, where time constraints are particularly acute, these barriers may be amplified. An illustrative study utilized self-administered digital methods to gather patient information before their physician encounter. Patients found these approaches instrumental in enhancing their communication with healthcare providers, improving the overall quality of their care.
Collectively, these studies underscore the pressing need for innovative solutions in medical history-taking, especially in high-stress settings like the emergency department.
CyrenCare, with its streamlined information collection, multilingual support, and reduced documentation burdens, is poised to address these limitations and provide a more efficient and accurate approach to gathering patient histories.
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Mazer, M., Deroos, F. J., Hollander, J. E., & McCusker, C. (2002). Medication history taking in emergency department triage is inaccurate and incomplete. Academic Emergency Medicine, 9(10), 1052-1057.
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James, T. L., Feldman, J., & Mehta, S. D. (2006). Physician Variability in History Taking When Evaluating Patients Presenting with Chest Pain in the Emergency Department. Academic Emergency Medicine, 13, 147-152.
- Berdahl CT, Moran GJ, McBride O, Santini AM, Verzhbinsky IA, Schriger DL. (2019). Concordance Between Electronic Clinical Documentation and Physicians’ Observed Behavior. JAMA Netw Open, 2(9)
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Arora, S., Goldberg, A. D., & Menchine, M. (2014). Patient Impression and Satisfaction of a Self-administered, Automated Medical History-taking Device in the Emergency Department. The Western Journal of Emergency Medicine, 15(1), 35-40
