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Physicians' impressions of old medical records
Insights
Physicians find hospital discharge summaries and dictated records more valuable than progress notes. Typewritten old medical records are preferred over handwritten ones for better clinical utility.
Area of Science:
- Medical Informatics
- Clinical Documentation
Background:
- Physician reliance on prior patient data is crucial for effective healthcare.
- Understanding the perceived value of different medical record types informs documentation practices.
Purpose of the Study:
- To assess physicians' perceived value of various historical medical record formats.
- To identify which types of old patient records are most beneficial for clinical decision-making.
Main Methods:
- Survey distributed to physician respondents.
- Data collected on the perceived utility of different medical record components.
Main Results:
- Hospital discharge summaries, old electrocardiograms (ECGs), and dictated summaries were highly valued.
- Progress notes and chart notes were generally considered of low value.
- Typewritten records were preferred over handwritten ones.
- Value of old x-ray reports, lab tests, and special test results showed divided opinions.
Conclusions:
- The format and type of historical medical records significantly impact their clinical usefulness.
- Prioritizing dictated and typewritten summaries may enhance information retrieval and patient care.
Abstract:
The physician respondents generally agreed that progress notes and chart notes are of little value to them and that hospital discharge summaries, old ECGs, and dictated summaries of the patient's medical records were of greater value. Although a majority of respondents felt old x-ray reports, results of old laboratory tests, and reports of special tests, such as cardiac catheterizations, pulmonary functions, and stress tests, to be of value, opinion was more nearly equally divided. In general, physicians valued old records that were typewritten over handwritten records.