Doctor-patient communication is an essential part of clinical practice and when performed effectively, establishes therapeutic relationships that contribute to the quality of patient care.

Beyond the exchange of information and knowledge, adept doctors try to foster better understanding of their patients, and details conveyed by patients – medical history, family history, allergies and lifestyle habits amongst other details – are documented in medical records, along with treatment plans and lab findings.

Medical records are essential for medical professionals to keep track of patient information and also serve as a communication tool between healthcare providers, but how well are they documented by medical professionals?

Disparities in self-reported symptoms and medical records

A recent study by researchers from the University of Michigan Kellogg Eye Center found wide discrepancies in the information provided by patients and the clinician’s documentation in the electronic medical records. Patients were given a 10-point pre-appointment questionnaire while waiting to see a physician, but doctors were not informed of the surveys and were unaware that their documented records would be reviewed for comparison.

Out of the 162 patients, only 38 patients’ medical records met the “exact agreement” with their individual responses in the survey.

"We found pretty noticeable differences between the two," says Dr Maria Woodward, an assistant professor of ophthalmology and visual sciences at the University of Michigan.

Symptom reporting was noted by authors of the study as a major inconsistency between the questionnaires and medical records, with a bias toward reporting more symptoms during the questionnaire.

Of all patients who reported symptoms of glare in their questionnaire, 91% did not have their concerns documented in their medical records. Similarly, only 20% and 25.6% of eye redness and eye pain respectively were documented by doctors in patient records.

"I think certainly the biggest takeaway is when people are presented things in different ways, they tell you different things,” said Woodward.

Medical records essential in patient care

Incomplete patient records are met with many drawbacks, one of which includes interrupted patient care during follow-up visits as doctors are unable to monitor the progression of disease, if initial symptoms are unreported. If other doctors or healthcare providers are referred to for continuity of care, they will also receive an incomplete picture of the patient’s condition, which ultimately affects the quality of patient’s care.

A patient’s medical history is often the most important component in making a clinical diagnosis, and missed or unrecorded symptoms may also lead to misdiagnoses or medical error.

There are many possible reasons for the disparities in what patients say and what doctors document. When interacting, patients may choose not to reveal, or overlook to mention all of their symptoms to their physicians. Time constraints may also pressure doctors to rush through the consultation, causing them to overlook details in a patient’s medical history.

Additionally, authors of the study also posit that doctors may not note down every detail provided by patients, especially if they are deemed as minor concerns that are not necessarily worth documenting.

"The concern highlighted by this research is that important symptoms may be overlooked. If a patient has severe symptoms, all of those symptoms should be documented and addressed,” Woodward explained.

Improving medical records with better communication

The findings have driven researchers to highlight the need for of better clarity of documenting patient records.

Hospitals like the Beth Israel Deaconess Medical Center in Boston, adopt a system that allows patients to access their doctor’s notes through an online portal, opening up opportunities for better communication and empowering patients to be more involved in their care. Through such methods, patients can also draw their doctor’s attention to any information that may be missing.

Implementation of pre-appointment questionnaires, similar to those in the study, could also be a simple yet effective method of resolving any gaps in patient records, according to Woodward.

Healthcare professionals should also be careful to cover and document all information revealed by patients, and run through details that have been recorded in the notes with patients to ensure that all important details have been noted down and addressed.

All in all, effective communication is crucial in ensuring that patient records are accurate and documented in detail. No doubt, well-documented patient notes are imperative in clinical practice, and like the art of communication, note-taking is a skill that is essential to ensure the quality of patient care. MIMS

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