Congruence of the Medical Record and Subject Interview on Time of Symptom Onset in Patients Diagnosed With Acute Coronary Syndrome.
Leslie L Davis, Thomas P McCoy, Barbara Riegel and 4 others
PMID 27749436WHAT IT FOUND
For patients with acute coronary syndrome, the symptom onset time recorded in the medical record differed from later patient interviews by a median of 45 minutes.
Interviews conducted more than 9 days after the event showed the largest discrepancies, making the medical record the more reliable source for this timing.
Key findings
01The median difference between the symptom onset time in the medical record and the patient interview was 45.0 minutes.
02Longer recall periods were significantly associated with greater differences between the two data sources.
03If the interview was more than approximately 9 days after the event, the difference between the two sources exceeded 30 minutes.
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
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What it does not show
Both the medical record and the interview relied on patient report, with no direct observation of the actual symptom onset time. The study excluded 25 patients who had a difference of more than 48 hours between the two sources, which may have removed cases with the most extreme discrepancies. The findings are from a secondary analysis of a specific trial population (patients with a history of cardiac disease) and may not generalize to all ACS patients.
The easy way to misread this
Do not assume the medical record is always accurate; it also relies on patient report. However, do not use later interviews to correct or replace the initial medical record documentation, as the study found these interviews were less complete and increasingly inaccurate as time passed.