Shimon A. Goldberg MD, Diana Neykin MD, Ruth Henshke-Bar-Meir MD, Amos M. Yinnon MD and Gabriel Munter MD
Background: Medical history-taking is an essential component of medical care.
Objectives: To assess and improve history taking, physical examination and management plan for hospitalized patients.
Methods: The study consisted of two phases, pre- and post- intervention. During phase I, 10 histories were evaluated for each of 10 residents, a total of 100 histories. The assessment was done with a validated tool, evaluating history-taking (maximum 23 points), physical examination (23 points), assessment and plan (14 points) (total 60 points). Subsequently, half of these residents were informed that they were assessed; they received their scores and were advised regarding areas needing improvement. Phase II was identical to phase I. The primary endpoint was a statistically significant increase in score.
Results: In the study group (receiving feedback after phase I) the physical examination improved from 9.3 ± 2.4 in phase I to 10.8 ± 2.2 in phase II (P < 0.001), while in the control group there was no change (11.3 ± 1.9 to 11.5 ± 1.8 respectively, P = 0.59). The assessment and plan component improved in the study group from 6.4 ± 2.7 in phase I to 7.4 ± 2.6 in phase II (P = 0.05), while no change was observed in the control group (8.2 ± 2.7 and 7.8 ± 2.3, P = 0.43). Overall performance improved in the study group from 30.4 ± 5.1 in phase I to 32.9 ± 4.5 in phase II (P = 0.01), a 10% improvement, while no change was observed in the control group (35.5 ± 6.0 to 34.6 ± 4.1, P = 0.4).
Conclusions: A review of medical histories obtained by residents, assessed against a validated score and accompanied by structured feedback may lead to significant improvement.