Effects of a Self-Administered Health History on New-Patient Visits in a General Medical Clinic

Self-administered health history questionnaires (SAHHQs) are widely used in ambulatory care settings to save provider time and to assure completeness of the clinical data base. A controlled, prospective study was undertaken in a general medical clinic to evaluate the impact of an extensively pretested, highly reliable, 120-item self-administered health history questionnaire developed for new patient visits. Seventy-seven patients were randomly assigned to the SAHHQ or control groups. Time analyses were performed on audiotapes of the encounters. Patients' charts were scored on explicit criteria for data completeness. Problem recognition was determined by comparison of pre-encounter and postencounter problem lists. SAHHQ and control visits did not differ significantly in total encounter time (44.7 versus 48.3 minutes, respectively). Less time was spent in SAHHQ encounters on data base questions (2.5 versus 3.9 minutes, p = .003). Chart data were more complete for SAHHQ patients (p less than .001). The completeness of senior staff charts was more affected by the presence of the SAHHQ than residents' charts (p = .03). Physicians tended to recognize more new problems in SAHHQ visits. Mutual (physician and patient) recognition of problems occurred more often in the SAHHQ visits (p = .05). Carefully designed SAHHQs increase recorded data base completeness and may increase problem recognition, but do not result in major time savings

Ambulatory · Chart · Family medicine · Health care · Medical history · Geriatric Care and Nursing Homes · Medicine · Nursing Diagnosis and Documentation · Primary Care and Health Outcomes · Surgery

• Outcome-Based Doctor-Patient Interaction Analysis

  Thomas S Inui, William B Carter et al.•Medical Care•1982

  Incluir item

• Fulfillment of patient requests in a general medicine clinic

  Richard F Uhlmann, W B Carter et al.•American Journal of Public Health•1984

  Incluir item