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The patient as a source to improve the medical record
M Lauteslager1, H J Brouwer, J Mohrs
1Department of General Practice, Academic Medical Center, Amsterdam, The Netherlands.
Background:
The problem list is an important tool in general practice for care as well as research purposes. As the central part of the problem-oriented medical record, it lists the main medical problems which the GP wants to have knowledge of during any patient encounter. The assessment of its quality is usually made by comparing with other sources of information on the patient's problems.
Objective:
This study addresses the question of to what extent the problem list can be improved by asking the patient about their own medical problems.
Methods:
During 7 weeks, all patients who visited three GPs in a health care centre in an Amsterdam suburb were interviewed. During the interview, they were confronted with the problem list made by their own GP and stimulated to make suggestions for addition or removal of problems.
Results:
All in all, patients were in agreement with 88% of all listed problems. The completeness of the problem list could be increased by 28%, while 4% ultimately were removed: a net gain of 24%.
Conclusion:
The patient can be used as a sourcetool for improvement of the quality of the problem list when its prime function is patient care. It becomes more complicated when the problem list also serves a research purpose. Clear inclusion rules will then have to be formulated.