Comparative Study of Quality Improvement in Interns’ History Taking by using a new medical history Form with Review of System Part and current one without this part

Document Type : Original Article

Authors

1 Shahid Beheshti University of Medical Sciences, Imam Hossein Clinical Research Development Center, Tehran, Iran

2 Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Abstract

Background: One of the most important steps in diagnosis and treatment of diseases is taking a good medical history. Current medical history form of Ministry of Health and Medical Education in our country doesn’t have Review of System part. In this research quantity and quality of Interns’ recording ROS in a new form including this part was studied.
Methods: This is a Quasi-experimental study. In control group current medical history form without ROS part and in the cases group new proposed form including ROS part were used to take medical history by interns. Quantity and quality of ROS writing were evaluated by Infectious Disease residents and specialists. All data were compared by K2 and Fisher T test in SPSS 24 software.
Results: In control group, 2% of interns had written ROS, all in incorrect place, with moderate quantity. In case group, ROS was written 100% in correct place, with quality of low, moderate, good, very good as 3%, 8%, 71% and 18% in order of frequency. Infectious disease residents’ and specialists’ satisfaction quality as low, moderate, good, very good were 8%, 14%, 72%, 6% and 7%, 15%, 71%, 7% in order with significant difference. (p <0.001)
Conclusions: In conclusion we found significant relation between quality and quantity of recording data with using medical history form with ROS part by interns. It is proposed to change current form to a new one with ROS part.

Keywords


1. Vivian N. Half A Century of Medical History. Medical History. 2007; 51:1–2.
 
2. Education Vice-Chancellor of Ministry of Health and Medical Education, general medicine education 2017.7.1. Available at: http://scume.behdasht.gov.ir/uploads/pezeshkiomoomi_96.pdf. Persian.
 
3.Poorgharehkhan A, Hekmatpu D, Mahdavian N, Zarie M, Karimi O. Exploration of Emergency Physician’s Experiences on Barriers of Precise Patient History Taking and Physical Examination: A Qualitative Study. Research in Medical Education 2017;8(1):3-11. Persian.
 
4. Kameli M.E, Vahedi Barzaki A, Behtaj F, Javadi Darabad M, Meidani Z, Ganjali R, Hosseini M, Mirzaei M. Documentation Guidelines of Medical Records in Ministry of Health and Medical Education, 2017April. Available at: http://iph.iums.ac.ir/files/iph/files/2.pdf. Persian.
 
5. Gaffari R, Amini A, Yazdani Sh, Alizadeh M, Salek Ranjbarzadeh F, Hassanzadeh Salmasi S; Comparative Study: Curriculum of Undergraduate Medical Education in Iran and in a Selected Number of the World’s Renowned Medical Schools. Iranian Journal of Medical Education 2012;11(7):819-31. Persian.
 
6. Education Vice-Chancellor of Shahid Beheshti University of Medical Sciences, general medicine education. Available at (http://msp.sbmu.ac.ir/index.jsp?siteid=74) (Persian & English)
 
7. Biographical description of the history and physical examination. Hospital Forms, Arash Printing House. Available at: http://chaparash.ir
 
8. Mashoufi M, Rostami Kh, Mardi A. Documentation of Medical Records by Physicians in the Hospitals under Ardabil University of Medical Sciences. Journal of Ardabil University of Medical Sciences. 2006;6(1):73-77. Persian.
 
9. Khazaee Z, Khazaee T, Namayi M. H. Jananeh E. The effective and preventive factors of taking patients' history from the viewpoint of the students of Birjand Medical School in 2010-2011. Journal of Medical Education and Development. 2013; 8(1): 14-21. Persian.
 
10. Sobhani A, Shojaei H, Vaghari S.A, Poormirzaei Sh, Aryanfar B, Ramezanian T. Assessment of record summaries and history taking in internal ward. The journal of Qazvin University of Medical Sciences, (New Name: Journal of Inflammatory Diseases) 2000;3(4):52-58. Persian.
 
11. Kiviri W, Wong R, Davis k, Rahimi L, Nyirasebura D, Bizimana T. Improving Patient Medical Record Organization in a Hospital Intensive Care Unit in Rwanda. Global Journal of Management and Business Research. Administration and Management. 2015; (15):13.
 
12. McCulloh RJ, Commers T, Williams DD, Michael J, Mann K, Newland JG. Effect of Combined Clinical Practice Guideline and Electronic Order Set Implementation on Febrile Infant Evaluation and Management. Pediatr Emerg Care. 2021,37(1): e25-31
 
13.Jiang BS, Yao PT, Ge YB, Yang M, Sun X, Ren JS, et al. Systematic review of methodological quality and reporting quality in gastric cancer screening guidelines. Zhonghua Yu Fang Yi Xue Za Zhi. 2020; 54(3):314-19.
 
14. Wiggins Petersen S, Rhoads J. Advanced Health Assessment and Diagnostic Reasoning. 2nd ed, Jones & Bartlett Publishers; 2014.
 
15. Jevon P, Odogwu S. Medical student survival skills. History taking and communication skills. Hoboken, NJ: Wiley-Blackwell; 2020.
 
16. Ian M. Medical history: Theory and history. London: Red Globe Press, Ulster University; 2018.
 
17. Roh H, Lee K, Eo E, Hong YS, Lee H, Jang BW, et al. Development of guide to clinical performance and basic clinical skills for medical students. Korean J Med Educ. 2015; 27(4):309-19. Korean. (Abstract).
 
18. Jane M. Orient Sapira's art & science of bedside diagnosis.5th ed. Philadelphia: Wolters Kluwer; 2019.
 
19. Tuite PJ, Krawczewski K. Parkinsonism: a review-of-systems approach to diagnosis. Semin Neurol. 2007; 27(2): 113–22.
 
20. Lynn S. Bickley, Peter G. Szilagyi, B Bates. Bates' Guide to Physical Examination and History Taking. Lippincott Williams & Wilkins; 2009.
 
 
21. Zakim D, Alscher MD, Schwab M, Schwalm B, Sundberg CJ. Medical history taking via computer can provide better care and research. Lakartidningen. 2014; 111(43):19025.
 
22. Charles E. Becker. Key Elements of the Occupational History for the General Physician. West J Med. 1982; 137(6): 581–82.
 
23. Bridge S.A competency history--an additional model of history taking. Aust Fam Physician. 2011; 40(9):735-8.
 
24. Woolliscroft JO, Calhoun JG, Beauchamp C, Wolf FM, Maxim BR. Evaluating the medical history: observation versus write-up review. J Med Educ. 1984; 59(1):19-23.
 
25. Ahmed AM. Deficiencies of history taking among medical students. Saudi Med J. 2002; 23(8):991-4.