Discrepancies between the medical record and the reports of patients with acute coronary syndrome regarding important aspects of the medical history

Chete Eze-Nliam,Kasey Bond,Keith Forlenza,Roy C Ziegelstein,Gina Magyar-Russell,Gayane Yenokyan,Kellie Cain,Rachel Jankowski

doi:10.1186/1472-6963-12-78

Abstract

BackgroundMany critical treatment decisions are based on the medical history of patients with an acute coronary syndrome (ACS). Discrepancies between the medical history documented by a health professional and the patient's own report may therefore have important health consequences.MethodsMedical histories of 117 patients with an ACS were documented. A questionnaire assessing the patient's health history was then completed by 62 eligible patients. Information about 13 health conditions with relevance to ACS management was obtained from the questionnaire and the medical record. Concordance between these two sources and reasons for discordance were identified.ResultsThere was significant variation in agreement, from very poor in angina (kappa < 0) to almost perfect in diabetes (kappa = 0.94). Agreement was substantial in cerebrovascular accident (kappa = 0.76) and hypertension (kappa = 0.73); moderate in cocaine use (kappa = 0.54), smoking (kappa = 0.46), kidney disease (kappa = 0.52) and congestive heart failure (kappa = 0.54); and fair in arrhythmia (kappa = 0.37), myocardial infarction (kappa = 0.31), other cardiovascular diseases (kappa = 0.37) and bronchitis/pneumonia (kappa = 0.31). The odds of agreement was 42% higher among individuals with at least some college education (OR = 1.42; 95% CI, 1.00 - 2.01, p = 0.053). Listing of a condition in medical record but not in the questionnaire was a common cause of discordance.ConclusionDiscrepancies in aspects of the medical history may have important effects on the care of ACS patients. Future research focused on identifying the most effective and efficient means to obtain accurate health information may improve ACS patient care quality and safety.

Highlights

Many critical treatment decisions are based on the medical history of patients with an acute coronary syndrome (ACS)
In our study, there was a considerable variability in agreement between important health conditions documented in the medical record and by the report of patients hospitalized with ACS
The poor agreement found with angina may be due to the fact that the history documented in the medical record was obtained soon after presentation to the hospital while the health history questionnaire (HHQ) was administered a few hours after the admission during which the patients may have received therapeutic interventions to ease their symptoms

Summary

Introduction

Many critical treatment decisions are based on the medical history of patients with an acute coronary syndrome (ACS). Discrepancies between the medical history documented by a health professional and the patient’s own report may have important health consequences. Total national costs (lost income, lost household production, disability and health care costs) of medical errors are estimated to be nearly $1 billion dollars, a significant amount due to associated health care costs [4]. Common causes of medical errors include adverse drug unstable angina pectoris (often referred to as “acute coronary syndrome or ACS”) since important ACS treatment decisions are based on the medical history. The aim of this study was to investigate the degree of agreement and sources of nonagreement between the documentation of ACS patients’ medical history as part of usual care and the patient’s selfreported health history during the same hospitalization

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