A retrospective audit of family history records in short-stay medical admissions

Med J Aust. 2010 Jun 21;192(12):682-4. doi: 10.5694/j.1326-5377.2010.tb03701.x.

Abstract

Objective: To retrospectively review the frequency and adequacy of family histories recorded from patients admitted to a short-stay medical unit in a tertiary teaching hospital.

Design, setting and patients: A formal audit of the medical records of 300 randomly selected patients who were admitted to the Royal Perth Hospital short-stay medical unit between July and December 2007.

Main outcome measure: Proportion of patient records with family history documents.

Results: Of the 300 patient records, 48 (16.0%) contained a family history with specific details about the presence or absence of a medical condition in at least one relative. Overall, 221 records (73.7%) had no family history documented. There was a trend towards more frequent and detailed family histories being recorded from younger patients and those presenting with chest pain.

Conclusions: Family history was seldom documented in patients admitted to a short-stay medical unit in a tertiary teaching hospital. An increased focus on family history taking among acutely ill patients offers potential health gains for patients and their high-risk relatives, particularly as preventive or risk-reducing health care strategies are emerging for a growing number of heritable disorders.

MeSH terms

  • Adolescent
  • Age Factors
  • Aged
  • Aged, 80 and over
  • Family Health*
  • Female
  • Genetic Predisposition to Disease
  • Humans
  • Male
  • Medical Audit*
  • Medical History Taking*
  • Middle Aged
  • Patient Admission*
  • Pedigree
  • Young Adult