Patient Medical History

It is questionable in some cases as to whether a physician actually completes the process of obtaining a patient’s medical history when the physician simply draws a diagonal line from the top right to the bottom left of the form and writes through the line “unremarkable” as noted in the following reality check.

Questionable Medical History Conducted

Smith was admitted to Community Hospital for surgery. Community Hospital medical staff bylaws require that a history and physical (H&P) test be completed prior to patients’ undergoing surgery. Smith’s attending physician did not complete the H&P form. He simply drew a diagonal line from the top right to the bottom left of the H&P, indicating that the patient had no history of or current disease processes.

The patient’s nurse, per hospital policy, completed a nursing assessment. The nurse documented on the patient admission assessment form that the patient had a history of transient ischemic attacks, diabetes, and hypothyroidism.

The anesthesiologist did not perform an anesthesia assessment before surgery. General anesthesia was administered without knowing the patient’s previous experiences, if any, with anesthesia.

Failure of the attending physician to complete an appropriate H&P examination and the anesthesiologist’s failure to perform a preanesthesia assessment placed the patient’s life and health at risk. The physician did not complete the H&P. He merely went through the motions of completing a H&P examination because it was mandated that the patient have an H&P in his medical record prior to surgery.

Ethical and Legal Issues

1. Discuss the ethical issues and principles violated in this case.

2. What are the potential legal issues of concern in this case?

3. Discuss what actions the organization should consider to improve the quality of H&P documentation.