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Are we failing to document adequate smoking histories? A brief review 1999-2009
Timothy H Self1, Jessica L Wallace, Lori Arnold Gray
1University of Tennessee Health Science Center; Methodist University Hospital, Memphis, TN 38163, USA. tself@uthsc.edu
Background:
Documenting a detailed smoking history is of obvious importance. Failure to adequately document the smoking history may result in the misdiagnosis and management of asthma, and may be associated with a deficiency of care in patients with cardiovascular disease and several other common diseases.
Scope:
The purpose of this article is to review the evidence over the past decade that demonstrates inadequate documentation of smoking history. A literature search of English language journals from 1999 to 2009 was completed using several databases, including PubMed, MEDLINE, EMBASE, and SCOPUS.
Findings:
Fourteen studies demonstrated inadequate documentation of smoking histories by primary care clinicians, specialists, residents, and medical students. Failure to document smoking histories was observed in patients with conditions such as heart failure, coronary artery disease, and asthma. Electronic decision support systems and simple medical record reminders were effective in improving the documentation of smoking histories.
Conclusions:
Failure to adequately document the smoking history appears to be common. Strategies such as electronic decision support systems are needed to correct this problem in order for patients to receive optimal therapy for their appropriate diagnoses.
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The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.