title: Is the medical record an accurate reflection of patients' symptoms during acute myocardial infarction?
abstract: Documentation of symptoms in the medical record provides clinicians and researchers with valuable information about the patient's experience during acute myocardial infarction (AMI). To examine the consistency between the patient's reported symptoms and the medical record, 215 patients were interviewed and their medical records examined for information about their admission symptoms. Chest pain was the most frequently reported and recorded symptom, and there was good agreement between the patient's report and the medical record. Although fatigue was the second most frequently reported symptom by patients, it was rarely documented in the medical record. Time of symptom onset was identified by 87.9% of patients but only documented in 60.5% of medical records. Clinicians may be recording those symptoms that support the AMI diagnosis and not those perceived to be less relevant. Findings suggest that the medical record is an inaccurate and inadequate source of information about patients' actual experience of AMI symptoms.
authors.affiliation: Marquette University.
authors.forename: Holli A
authors.initials: HA
authors.lastname: DeVon
authors.forename: Catherine J
authors.initials: CJ
authors.lastname: Ryan
authors.forename: Julie Johnson
authors.initials: JJ
authors.lastname: Zerwic
mesh_terms: D004282:Documentation / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008487:Medical History Taking; D008499:Medical Records; D008875:Middle Aged; D015146:Midwestern United States; D009203:Myocardial Infarction / Q000175:diagnosis* / Q000503:physiopathology; D011787:Quality of Health Care; D015203:Reproducibility of Results; D012650:Self Disclosure