Abstract
Clinical records organized and optimized for clinical integration and clinical decision making.
Highlights
One of the most basic and cost effective skills a healthcare professional (HCP) can employ is correctly diagnosing (90%) a patient by taking an accurate medical history.[1,2] A HCP will diagnosis and develop a treatment plan by requesting the following information from the patient: chief compliant, history of present illness, past medical and surgical history, medication history, family history, social history, and conducting a review of systems
The process of having multiple HCPs ask the same or similar questions at multiple points would improve the odds that information will be remembered/revealed, and this approach would be much more likely to be useful in a typical clinical setting
We propose that interprofessional education and collaboration in history taking will lead to the effective capturing and communication of patient information resulting in the best patientcentered outcomes
Summary
One of the most basic and cost effective skills a healthcare professional (HCP) can employ is correctly diagnosing (90%) a patient by taking an accurate medical history.[1,2] A HCP will diagnosis and develop a treatment plan by requesting the following information from the patient: chief compliant, history of present illness, past medical and surgical history, medication history, family history, social history, and conducting a review of systems. HCPs have used one of two major clinical reasoning paradigms for providing health care: decision making and problem solving.[3,4,5,6] the successful implementation of these paradigms is contingent on complete and accurate documentation of clinical information and the availability of this information for medical decision making This ideal is rarely met with the current medical record, as it is often proprietary and provider specific. The process of having multiple HCPs ask the same or similar questions at multiple points would improve the odds that information will be remembered/revealed, and this approach would be much more likely to be useful in a typical clinical setting. We propose that interprofessional education and collaboration in history taking will lead to the effective capturing and communication of patient information resulting in the best patientcentered outcomes
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