Advances in technology, genetic testing, and genomic medicine are revolutionizing patient care. Yet the mainstay of diagnostic work is still the patient history.
This is especially true in primary care. However, as primary care physicians become increasingly strapped for time—spending less time with patients and more time on documentation, coding, and quality-improvement efforts1—obtaining detailed patient histories has become more challenging.
Read on for tips and solutions that can help inform more complete patient histories.
Patient history: an important diagnostic tool
Accurate, well-documented patient medical histories provide a foundation for patient diagnosis and treatment, as they encapsulate the social, environmental, hereditary, and behavioral factors contributing to a patient’s well-being.
Patient history is also one of the key drivers of precision medicine. Knowing whether a patient is at risk for a specific disease—and whether to test and/or treat for it—can begin with knowing the patient’s history.
The challenges of obtaining a complete patient history
Despite the continued importance of the patient history, obtaining complete records has become more challenging for primary care physicians.
Why? Time constraints, for starters. According to recent estimates, the average primary care visit must deal with 7.1 issues in roughly 18 minutes.2 That’s a lot of ground to cover, leaving little time for history-related interviewing that may or may not be relevant to the issue(s) at hand.
And while many physicians turn to their electronic health record (EHR) for patient history, EHR data can often be incomplete or missing. In a recent study, roughly 75% of healthcare leaders said that incomplete and inaccurate medication data remains a top concern.3
But accurate histories are vital. An inaccurate patient history can potentially lead to a delay in diagnosis, unnecessary testing, or a worsening condition.4
A few tips to help inform more complete patient histories
You know your patients—and their histories—best, but below are a few tips that can help you fill in missing or incomplete information in your patients’ histories.
- Ask about changes to patient history during each visit—including any new medications, conditions, allergies, or social/environmental changes (e.g., a new job, a move, the health status of a family member)
- Review all histories taken by other staff members—particularly if the patient displays a confusing clinical presentation
- Always review a patient’s history before or during a visit, if possible, to address any gaps—is what the patient is telling you supported by your EHR?
Data analytics tools can also help you fill gaps in patient history—enabling a more efficient and thorough patient assessment.
Data Diagnostics® can provide more insight into patient medical history
Data Diagnostics with Historical Data-Related reporting from Quest can provide you with a more detailed patient medical history—to inform diagnosis, potentially reduce encounter time, and aid in patient evaluation for more efficient and improved care.
These reports can help you get accurate information when patients are unable to provide it or for patients you’ve never seen before. As a result, you can reduce costs by avoiding unnecessary duplicative evaluations or tests.
Establishing a solid foundation—more complete patient histories—can help you improve quality of care and both patient and practice health.
1. Sinsky C, Colligan L, Ling L, et al. Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties. Ann Intern Med. 2016;165(11):753-760.
2. Zamosky L. Chronic disease: A growing challenge for PCPs. Medical Economics. Available at medicaleconomics.modernmedicine.com/medical-economics/content/tags/chronic-disease/chronic-disease-growing-challenge-pcps. Accessed July 7, 2017.
3. Rosin T. Study: 75% of hospital executives concerned patient medication data is incomplete, inaccurate. Becker’s Healthcare. Available at www.beckershospitalreview.com/healthcare-information-technology/study-75-of-hospital-executives-concerned-patient-medication-data-is-incomplete-inaccurate.html. Accessed August 29, 2017.
4. Gupta K. The importance of listening to a patient’s history. Boston.com. 6 Jan 2013. Available at www.boston.com/uncategorized/noprimarytagmatch/2013/01/06/the-importance-of-listening-to-a-patients-history. Accessed August 29, 2017.