A complete and accurate history is the foundation for all future patient care — whether maintenance and wellness care, or diagnosis and treatment of acute or chronic conditions.
Posted in Risk Management on Friday, October 9, 2020
In spite of all of the technology available today, the history is still the mainstay of the patient journey. The impact of social, environmental, hereditary and behavioral factors on patient well-being and illness must be realized in the patient’s history
The accuracy and completeness of the information contained in a patient’s history is essential for optimal patient care. A complete and accurate history is the foundation for all future patient care—whether maintenance and wellness care, diagnosis and treatment of acute or chronic conditions.
Important Points to Remember
- Ask the patient about changes or additions to the history at each visit, including:
- New or discontinued medications
- New conditions
- New allergies
- Changes in socio- or demographic information:
- Marital status
- Job status
- Health status of a family member
- Travel outside of the U.S.
Pay particular attention to changes in medications and be aware that patients may be seeing other providers who are prescribing medications or therapies. Drug-to-drug interactions are a significant cause of patient morbidity and mortality and medical malpractice actions against the prescriber. Any changes may impact your plan of care.
Carefully review any initial history obtained by staff to clarify, confirm and elicit more details to address any blank or “N/A” areas. The doctor is ultimately responsible and should regularly review the information gathered, especially when the patient displays a confusing clinical presentation.
Be aware that doctors are still accountable for knowing the information in the patient’s chart.
Additional Resources
CDC: Family Health History