Expert Recommendations for Documenting an Older Patient’s Medical History

Medical History

The medical record is a medical and legal document that contains information about a patient’s health and medical history. The History and Physical (H&P) is fundamental part of a medical transcription service provider’s work and the first report added to the patient’s medical record when physicians see the patient for the first time. The H&P is crux of the medical treatment plan and the most important tool in the exam of the patient in the emergency department. When it comes to an older patient, a proper medical history and physical exam is critical for correct diagnosis and appropriate treatment.

The components of the H&P are: chief comp, present illness, past history, review of systems, physical exam, problem list and differential diagnosis. For older adults, physiology of aging and pathologic conditions related to aging can make diagnosis difficult. The National Institute of Aging (NIA) recommends that in addition to medical and family history details, the history for geriatric patients should include information about their social circumstances and lifestyle.

General Recommendations

According to the NIA and other valid sources, there are several factors that physicians should take into account when documenting older patients’ medical history:

  • It may take more time (even several sessions) as the patient may take more time to explain things or because of sensory impairment and cognitive decline.
  • It would be a good idea to obtain preliminary information before the consultation using printed (use large font) forms sent by email.
  • Choose the question format – open-ended or simple yes-no questions – based on the patient’s ability to respond.
  • Before evaluating the current illness, get the medical history immediately after the chief complaint. This will make it easier to understand the patient condition.
  • Though information is best obtained first-hand from the patient, caregivers or other sources should be contacted to if doubts arise.
  • The provider should refer to the mental health status report if the patient’s responses are clearly inadequate or inappropriate.
  • Make sure that patients only have to tell their story once. Also, find out if anything has changed since their last visit – whether living arrangements have changed or they have experienced any personal loss.
  • The physician should sit facing the patient at eye level and speak slowly and clearly, with good lip movement. Questions should be presented in print if the patient has hearing issues.
  • Pay attention when patients express their concerns – this in itself can be therapeutic and build trust.

Areas Needing Special Attention

  • Current Issues: Older patients may have multiple health issues. The focus should be on what’s currently troubling them the most. Certain medical conditions can increase risk for severe illness. Older adults diagnosed with COVID-19 are at greater risk of severe illness and hospitalization or death.
  • Functional Assessment: Functional impairments and cognitive and affective problems are common among older patients. The physician should ask questions to identify impairments in Basic Activities of Daily Living and Instrumental Activities of Daily Living. Recognizing these impairments would enable appropriate management or referral.
  • Medications: Polypharmacy and misuse of medications can lead to many health complications in older adults. It’s important to ask patients about all their prescription and over-the-counter medications and dosages as well as any alternative treatments and dietary supplements they may be using. A widely recommended strategy is to ask patients to bring along their medications in a paper bag.
  • Family History: The NIA notes that getting information about family history is important not only to understand the patient’s genetic risks but also to get information about the health of family members or relatives taking care of the patient and the kind of support that they can provide, if needed.
  • Social and Nutritional History: Assessment of social history will help reveal issues related to lifestyle, affect, cognition, function, values, health beliefs, cultural factors and caregiver support. Getting information about the patient’s home can provide an understanding their illness and might improve adherence to treatment. Nutritional assessment can identify risk of malnutrition and whether referral for dietetic consultation is necessary

All members of the patient’s care team refer to the H&P right from the point of its creation. The H&P remains a central element in the patient record even as additional reports are added on in repeat visits to document progress, interventions, surgery and so on. While the H&P for a patient with not-so-serious concerns may be brief, the reports for older patients with multiple chronic conditions are likely to be detailed and lengthy. Accurate and timely medical chart documentation by an experienced medical transcription company can go a long way in helping physicians focus on the consultation and interviewing older patients to elicit all the information relevant to their care.