LAUSR

Patient Coauthored History Could Improve Health Record Accuracy To the Editor The article by Valikodath et al1 showcases a problem with modern health records: documentation does not always match the patient’s concerns. The authors conclude that electronic medical record data may not provide a comprehensive resource for clinical practice or “big data” research. I agree that a solution may come from patient-generated information. In a previous report,2 patients were invited to complete a replica of a history as defined by the Centers for Medicare and Medicaid Services. Patients completed a 3-page prehistory form with approximately 30 questions in a structured format that included chief complaint(s), a history of present illness, the status of chronic condition(s), a review of systems, and a past family social history.3 A total of 263 patients who were aged 14 to 94 years completed the form in preparation for a family physician visit. On arriving to the office, the prehistory form was scanned into the electronic health record as a document and the content was transcribed by a staff member into the history component of the encounter note. The prehistory was recognized as a written request to amend the health record per the Health Insurance Portability and Accountability Act Privacy Rule (45 C.F.R. § 164.526). I was the physician who conducted the medical encounters for patients with a prehistory and I can attest to the improvement in medical record accuracy. I was able to enter the examination room, greet the patient, and then read the patient’s narrative, all of which was documented in the record. I finished the history with specific questions and then performed a pertinent examination. Any medical decision making occurring readily transformed to shared decision making because the patients were engaged and I was relieved of clerical burdens. After seeing the physician, each patient was given a paper copy of the encounter note at the checkout window. Patients were instructed to go home, read their record, and score it with an anonymous survey. Patients who completed a prehistory form in preparation for a medical encounter reported feeling better heard and understood. Medical record inaccuracy could adversely affect patient safety and data analytics. These comments suggest that a prehistory form potentially may be a means of improving health record accuracy.