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

BMC Health Serv Res. 2012 Mar 26;12:78. doi: 10.1186/1472-6963-12-78.

Abstract

Background: 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 therefore have important health consequences.

Methods: Medical 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.

Results: There 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.

Conclusion: Discrepancies 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.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Acute Coronary Syndrome* / complications
  • Acute Coronary Syndrome* / diagnosis
  • Aged
  • Cross-Sectional Studies
  • Educational Status
  • Female
  • Health Status
  • Health Status Indicators*
  • Hospitalization / statistics & numerical data
  • Humans
  • Male
  • Medical History Taking / methods*
  • Medical Records*
  • Middle Aged
  • Patients / psychology*
  • Patients / statistics & numerical data
  • Quality Assurance, Health Care / standards
  • Self Report*
  • Surveys and Questionnaires