Discrepancies between the medical record and the reports of patients with acute coronary syndrome regarding important aspects of the medical history

Eze‐Nliam, Chete; Cain, Kellie; Bond, Kasey; Forlenza, Keith; Jankowski, Rachel; Magyar‐Russell, Gina; Yenokyan, Gayane; Ziegelstein, Roy C.

doi:10.1186/1472-6963-12-78

Cited by 23 publications

(19 citation statements)

References 28 publications

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“…Participants were excluded if they scored below 24/30 on the Mini-Mental Status Examination (MMSE), 18) were intubated or sedated more than 3 days after hospital admission, or if cocaine or other recreational drugs were found on toxicology screen. Procedures: Baseline demographic characteristics and medical history were obtained for consenting patients using a health history questionnaire developed by the authors 19) and by medical record review. For medical diagnoses, we used the same categorizations and definitions as those used for the Charlson Comorbidity Index (CCI).…”

Section: Methodsmentioning

confidence: 99%

“…For medical diagnoses, we used the same categorizations and definitions as those used for the Charlson Comorbidity Index (CCI). 20) Because we have previously found discrepancies between diagnoses obtained from the medical record and those reported by the patient, 19) and because the likelihood of inaccurate documentation increases as more specific information about the diagnosis is required, we used categories that were broader than those used in calculating the CCI for certain diagnoses; these are noted in Table I. Only medical diagnoses occurring in at least 5% of the sample are reported.…”

Section: Methodsmentioning

confidence: 99%

“…The ISI consists of 7 items with responses ranging from 0 to 4, producing total scores of 0-28. Total ISI scores are categorized into: no clinically significant insomnia (0-7), subthreshold insomnia [mild (8)(9)(10)(11)(12)(13)(14)], moderate clinical insomnia (15)(16)(17)(18)(19)(20)(21), and severe clinical insomnia (22)(23)(24)(25)(26)(27)(28). A cutoff score of 14 has been shown to distinguish individuals meeting criteria for primary insomnia from normal sleepers.…”

Section: Methodsmentioning

confidence: 99%

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Clinical Correlates of Insomnia in Patients With Acute Coronary Syndrome

et al. 2013

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SummaryThis study sought to examine the prevalence of insomnia and its association with depression, anxiety, and medical comorbidities in patients after an acute coronary syndrome (ACS). Insomnia increases risk of recurrent cardiac events in ACS patients, but little is known about the prevalence and clinical correlates of insomnia in this setting. Patients (n = 102, 58.3 ± 10.6 years-old) admitted for ACS to a cardiology service at an urban academic medical center completed the Insomnia Severity Index, Epworth Sleepiness Scale, and measures of depression and anxiety. A subset (n = 20) completed ambulatory polysomnography (PSG) in their homes several weeks after discharge. Moderate or severe insomnia was reported by 37% of patients during hospitalization and was associated with 76 minutes more wake after sleep onset measured by home PSG. Although depression and insomnia were strongly associated, about 1 in 4 patients with insomnia did not report significant depressive symptoms. Sleep apnea was documented in 80% of patients on PSG, but insomnia was not associated with sleep apnea, periodic limb movements, demographic factors, or medical conditions other than liver disease. Insomnia is present in over one-third of ACS patients during hospitalization, but at-risk patients could not be readily identified by demographic or medical factors or by depression symptoms. (Int Heart J 2013; 54: 258-265) Key words: Sleep, Myocardial infarction, Angina, Depression A s many as 1 in 3 patients with acute coronary syndrome (ACS) suffer from significant psychological distress, such as depression and anxiety.1,2) Among ACS patients, depression and anxiety are associated with increased mortality, 3,4) diminished quality of life, 5) increased health care costs, 6) and reduced adherence to recommendations intended to decrease the risk of cardiac events. 7) Although insomnia is common among individuals with psychological distress, the literature on depression and anxiety as risk factors for ACS morbidity and mortality has largely ignored its potential impact in ACS patients. Instead, most of the literature on sleep in patients with heart disease has focused almost exclusively on sleep apnea due to known associations between sleep-disordered breathing (SDB) and cardiovascular morbidity. 8) Insomnia, however, is often unrelated to SDB 9,10) and is important to consider in ACS patients since poor sleep quality is associated with a 2.5-fold increased risk of recurrent cardiac events in women after an ACS.11) Insomnia has also been linked to increased morbidity, 12) mortality, 13) and health care costs 14) independent of psychological distress and in some cases, independent of SDB and periodic limb movements as well. 12)To our knowledge, no study has examined insomnia in an ACS population using a reliable, validated self-report instrument of insomnia severity that not only assesses sleep continuity and quality, but also inquires about important consequences of poor sleep, such as daytime impairment or distress.15-17) As such, this study ...

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Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

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Clinical Correlates of Insomnia in Patients With Acute Coronary Syndrome

et al. 2013

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“…We did not include patients who had mild troponin elevation and went for coronary angiogram without undergoing nuclear stress test, which may be a higher-risk group. Clinical risk factors in our study were obtained from chart documentation and were not independently verified from the patients, while discrepancies have been noted between the medical history documented by healthcare professionals and the reports of the patients with acute coronary syndrome (11).…”

Section: Discussionmentioning

confidence: 99%

Mild troponin I elevation does not predict ischemia on myocardial perfusion imaging

Abbas

Rao

2017

HEART

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“…[7] studied the discrepancies between the medical records and the reports of patients with acute coronary syndrome regarding important aspects of the medical history and stated “It is possible that patients may not be able to reliably recall health conditions due to the stress of acute illness or the hospitalization itself, or while being treated with certain medications.”…”

Section: Introductionmentioning

confidence: 99%

Discrepancies between dental and medical records of cardiac patients in AlHada Armed Forces Hospital, Taif, Saudi Arabia

Al-Raddadi

2016

J Int Soc Prevent Communit Dent

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Aims and Objectives:This study aims to estimate the prevalence of medical information discrepancies between dental and medical records of cardiac patients at AlHada Armed Forces Hospital in Taif and to identify the factors contributing to these information discrepancies.Materials and Methods:The study applied a descriptive retrospective medical and dental records review of a stratified proportional sample of 289 cardiac patients, which was extracted from 1154 cardiac patients who visited both the cardiology and dental clinics at the AlHada Armed Forces Hospital between 2007 and June 2012. Data were analyzed using the Statistical Package for the Social Sciences version 19.Results:The main results of this study are the following: The mean and standard deviation of patient's age was 56 ± 16.9, female patients represented 47.8% of the study population. A total of 78.5% of dental records were documented by dental residents whereas 48.4% of the dentists had more than 6 years of experience. Two hundred and seventy-nine (96.5%) of the 289 dental records had medical information discrepancies compared to the corresponding medical records. One hundred percent of systemic lupus erythematosus and rheumatic fever cases were not documented in the dental records followed by 93% of medications, 92% of stroke, and 88.5% of hyperlipidemia, whereas the least prevalent were cardiac disease (26%) and diabetes mellitus (22.2%).Conclusion:Approximately 75% of the patients who directly or indirectly accessed the dental services showed discrepancies. The researcher concludes that critical information gaps exist between dental and medical records that mostly attributed to system level problems. A well-established model for efficient communication among medical and dental care providers caring for cardiac patients does not appear to exist. The absence of such a model can threaten the overall health of patients.

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Discrepancies between the medical record and the reports of patients with acute coronary syndrome regarding important aspects of the medical history

Cited by 23 publications

References 28 publications

Clinical Correlates of Insomnia in Patients With Acute Coronary Syndrome

Clinical Correlates of Insomnia in Patients With Acute Coronary Syndrome

Mild troponin I elevation does not predict ischemia on myocardial perfusion imaging

Discrepancies between dental and medical records of cardiac patients in AlHada Armed Forces Hospital, Taif, Saudi Arabia

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