From patient talk to physician notes—Comparing the content of medical interviews with medical records in a sample of outpatients in Internal Medicine

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• 作者：Wolf A. Langewitz ; Yael Loeb ; Matthias Nü ; bling ; Sabina Hunziker
• 关键词：Physician notes ; Documentation ; Communication skills ; Interview content ; Charts ; Medical records
• 刊名：Patient Education and Counseling
• 出版年：2009
• 出版时间：September 2009
• 年：2009
• 卷：76
• 期：3
• 页码：336-340
• 全文大小：263 K

文摘

Objectives

An increasing number of consultations are delivered in group practices, where a stable 1:1 relationship between patient and physician cannot be guaranteed. Therefore, correct documentation of the content of a consultation is crucial to hand over information from one health care professional to the next.

Methods

We randomly selected 20 interviews from a series of 56 videotaped consultations with patients requesting a general check-up exam in the outpatient department of Internal Medicine at the University Hospital Basel. All patients actively denied having any symptoms or specific health concerns at the time they made their appointment. Videotapes were analysed with the Roter Interaction Analysis System (RIAS). Corresponding physician notes were analysed with a category check-list that contained the information related items from RIAS.

Results

Interviews contained a total of 9.002 utterances and lasted between 15 and 53 min (mean duration: 37 min). Patient-centred communication (Waiting, Echoing, Mirroring, Summarising) in the videos significantly correlated with the amount of information presented by patients: medical information (r = .57; p = .009), therapeutic information (r = .50; p = .03), psychosocial information (r = .41; p = .07), life style information (r = .52; p = .02), and with the sum of patient information (r = .64; p = .003). Even though there was a significant correlation between the amount of information from the video and information in physician's notes in some categories (patient gives medical information; Pearson's r = .45; p = .05, patient gives psychosocial information; Pearson's r = .49; p = .03), an inspection of the regression lines shows that a large extent of patient information is omitted from the charts. Physicians never discussed with patients whether information should be documented in the charts or omitted.

Conclusions

The use of typical patient-centred techniques increases information gathered from patients. Physicians document only a small percentage of patient information in the charts, their ‘condensing heuristic’ is not shared with patients.

Practice implications

Patient involvement should be advocated not only to medical decision making but also to the way physicians document the content of a consultation. It is a joint responsibility of patient and health care professional to decide, which information should be kept and thus be communicated to another health care professional in future consultations.