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

Langewitz, Wolf A. and Loeb, Yael and Nübling, Matthias and Hunziker, Sabina. (2009) From patient talk to physician notes-Comparing the content of medical interviews with medical records in a sample of outpatients in Internal Medicine. Patient education and counseling, Vol. 76. pp. 336-340.

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Official URL: http://edoc.unibas.ch/dok/A6004137

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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 53min (mean duration: 37min). 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.
Faculties and Departments:03 Faculty of Medicine > Bereich Medizinische Fächer (Klinik) > Psychosomatik > Psychosomatik (Langewitz)
03 Faculty of Medicine > Departement Klinische Forschung > Bereich Medizinische Fächer (Klinik) > Psychosomatik > Psychosomatik (Langewitz)
UniBasel Contributors:Langewitz, Wolf Axel
Item Type:Article, refereed
Article Subtype:Research Article
Publisher:Elsevier Science
Note:Publication type according to Uni Basel Research Database: Journal article
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Last Modified:24 May 2013 09:12
Deposited On:26 Apr 2013 06:52

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