Background: Internal Medicine residents and interns are often the first contact for newly admitted patients in a teaching hospital. The proper evaluation, diagnosis, and treatment may depend on this initial encounter.
Objectives: To evaluate the history-taking and physical-examination skills of interns/residents on new admissions to the medical floors; to compare data from the patient encounter to the chart for evidence of accuracy; to measure the time spent on the initial encounter.
Methods: An independent medical observer used a yes/no checklist with 60 variables in a single-blinded observational study. Frequency tables were generated and results were based on descriptive statistics.
Results: In 7 categories specifically aimed at chart review for accuracy, discrepancies were found between what medical post-graduate year (PGY)-1 interns and PGY-2 residents (interns/residents) recorded in the patient's chart and the observed actions during the patient encounter. There were 25 encounters observed. In 64%, the time spent on history taking was <7 minutes. In 68%, the time spent for the physical examination was <5 minutes. In 72%, patients were notasked about family medical history. None ofthe observed interns/residents took their own measurements of the patient's blood pressure. No intern/resident asked about recent weight loss, weight gain, level of salt intake, despite patients with history of hypertension; nor did they perform any examinations of the eye fundi and accommodation, thyroid, carotids, or hearing. The majority of patients were asked about chest pain, cough, nausea, vomiting, chief complaint, and the onset of symptoms.
Conclusions: This study documents the poor overall performance in the quality of history-taking and physical-examination skills on newly admitted patients.