Tuesday, January 10, 2017

The Need for Revision: Traditional History and Physical “Write-up” Provides Inadequate Context for Sharing Patient Information

Brown JL. Communication pitfalls associated with traditional history and physical write-up documentation. Adv Med Ed Pract 2016; 2017(8): 37-41 DOI http://www.ncbi.nlm.nih.gov/pubmed/28096709

The decades-old traditional “write-up” outline used for documenting patient encounters and giving oral presentations provides inadequate context for sharing clinical information: The examiner’s observations made at the start of a patient encounter are described out of sequence ­― after the patient’s history and chief concerns have already been presented.

An experienced clinician correctly understands that diagnosis and treatment begin when patients enter the examination room. The examiner’s early perceptions about the patient's demeanor, severity of illness, level of distress, and obvious abnormalities can affect patient-clinician interaction, triage, content and accuracy of the history, and clinical reasoning: Patients reporting the same chief concern of “chest pain” are likely to be asked different questions with different focus and interpretation of responses when the examiner perceives the patient to be well, in severe pain, dyspneic, toxic, or clinically depressed. Together with background information that includes age, gender, cultural identification, and occupation, these observations are used to place concerns and history in the context of the patient as a person rather than as an intellectual challenge. (“It is more important to know what sort of person has a disease than to know what sort of disease a person has.” – Hippocrates.)

It has been traditional but not entirely reasonable to categorize the patient's "general appearance" in physical findings because they are as pertinent to the history-taking process as they are to conducting a proper examination. To enable others to interpret the history using the same mindset and context as the examiner, it is necessary for early perceptions to be shared before rather than after the chief concerns and history have already been presented.

Perpetuating use of the unofficial but widely-used write-up outline deemphasizes the importance of creating context when formulating diagnoses and sharing clinical information. Suggestions to improve documentation and oral presentations include placing greater emphasis on teaching contextual methodology and modifying the outline sequence to conform to clinical practice. This modification can be incorporated into most electronic health records by adding early observations to the background information or the chief concerns. Objective and subjective components can still be identified by qualifying them with appropriate language: "This acutely-ill appearing Hispanic male states that he has been having headaches for the past two weeks,"

These needed changes have the potential to decrease miscommunication and clinical error. They also teach the importance of context as a basic principle of clinical reasoning


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