Patient recall - strengths and shortcomings of a major information source

Abstract

Physicians rely on patients for needed information about past medical events, implying a belief that patients are able to understand, recall and verbalize past medical events accurately and reliably. Is this belief valid? This article discusses: 1) whether patients are accurate and reliable reporters of their own health status, medical events and medical history; 2) whether the physician is able to make correct diagnoses and prognoses based upon information provided by patients; and 3) factors that affect recall. In some ways patients are good reporters of their medical history. However, there are numerous factors that affect reporting accuracy and reliability such as: anxiety, mood, severity of illness, type and duration of a procedure, and length of time since the medical episode. Good communication appears to be a key element in eliciting accurate and reliable patient recall. Physician records remain the best source of patient information and many points of information gleaned from patients may be used with confidence. Recognizing that physician records are the repository of the best medical information about individual patients means that more needs to be done to ensure that high priority is placed upon medical record documentation, format, and sharing. It is unlikely that physician records will ever fully replace the role of the patient as a personal medical historian.