History and Physical Documentation - Are We Meticulous?

Authors

Monica Alexanderson, University of LynchburgFollow

Abstract

ABSTRACT:

Objective: An error on a hospital history and physical (H&P) may be perpetuated by subsequent providers in the continuum of healthcare. Inaccurate medical documentation can result in patient harm, death, malpractice lawsuits, insufficient coding and underbilling. Advanced-practice providers (APP) frequently complete admitting H&P documentation in hospital settings. A systematic review of the literature was completed to examine H&P and APP documentation as well as quality improvement processes to decrease errors and improve accuracy of H&Ps.

Methods: A systematic review of the literature was completed utilizing databases including PubMED, MEDLINE and the Cochrane Library to search relevant English language, peer-reviewed journal articles available in the University of Lynchburg system. Dates were limited to 2008 through 2019.

Results: Few published studies address quality improvement with regards to documentation, particularly for APPs. Models used for medical education lack studies supporting efficacy. Clinical quality improvement processes have not included APPs nor specific H&P documentation.

Conclusions: While accurate and thorough H&P documentation has the potential to avert medical errors, patient harm and subsequent malpractice suits, quality improvement processes have not been tested in RCTs to prove efficacy. Specifically, research utilizing APPs and H&Ps should be addressed in future studies.

Keywords: documentation, medical errors, medical history, malpractice, physician assistant, nurse practitioner, trends, quality improvement

Recommended Citation

Alexanderson M. History and Physical Documentation - Are We Meticulous?. University of Lynchburg DMSc Doctoral Project Assignment Repository. 2020; 2(2).