A Pilot Study of the Chronology of Present Illness: Restructuring the HPI to Improve Physician Cognition and Communication

Abstract

BACKGROUND: Patient history-taking is an essential clinical skill, with effects on diagnostic reasoning, patient-physician relationships, and more. We evaluated the impact of using a structured, timeline-based format, the Chronology of Present Illness (CPI), to guide the initial patient interaction. OBJECTIVE: To determine the feasibility and impact of the CPI on the patient interview, written notes, and communication with other providers. DESIGN: Internal medicine residents used the CPI during a 2-week night-float rotation. For the first week, residents interviewed, documented, and presented patient histories according to their normal practices. They then attended a brief educational session describing the CPI, and were asked to use this method for new patient interviews, notes, and handoffs during the second week. Night and day teams evaluated the method using retrospective prepost comparisons. PARTICIPANTS: Twenty-two internal medicine residents in their second or third postgraduate year. INTERVENTION: An educational dinner describing the format and potential benefits of using the CPI. MAIN MEASURES: Retrospective pre-post surveys on the efficiency, quality, and clarity of the patient interaction, written note, and verbal handoff, as well as open-ended comments. Respondents included night-float residents, day team residents, and attending physicians. KEY RESULTS: All night-float residents responded, reporting significant improvements in written note, verbal sign-out, assessment and plan, patient interaction, and overall efficiency (p < 0.05). Day team residents (n = 76) also reported increased clarity in verbal sign-out and written note, improved efficiency, and improved preparedness for presenting the patient (p < 0.05). Attending physician ratings did not differ between groups. CONCLUSIONS: Resident ratings indicate that the CPI can improve key aspects of patient care, including the patient interview, note, and physician-physician communication. These results suggest that the method should be taught and implemented more frequently.

Preferences in Oncology History Documentation Styles Among Clinical Practitioners

“…Comparing archetypal examples of narrative and chronologic oncology histories, respondents preferred the chronologic format, confirming pilot work. 27 The chronologic history was preferred for both preparation for a visit with an unknown patient (66% preference) and for preparing one's own note (77% preference). The chronologic summary was preferred in four of the five measured attributes, whereas the narrative summary was favored for thoroughness.…”

“…25,26 A pilot intervention study using the CPI showed improvements in the clarity of both written notes and verbal sign-out and more efficient sign-out. 27 Interest has risen in structuring a CPI within the EHR. One EHR vendor (Epic) has embedded a chronologic oncology documentation system that allows quasistructured documentation of care events labeled with locally specified categories (eg, surgery, diagnostic imaging, and systemic therapy).…”

Sustainable Engaged Accountable Learners

“…These are critical components in any meaningful learning experience in medicine 3,9 . Examples of educational interventions that promote self‐regulation and positive interprofessional relationships include “Best and Worst Days” case discussions, use of Skeff’s “Chronology of the Present Illness” framework, and autonomy‐supportive changes to the learning climate 10,31,32 …”

Reorganizing the History of Present Illness to Improve Verbal Case Presenting and Clinical Diagnostic Reasoning Skills of Medical Students: The All-Inclusive History of Present Illness

“…The emphasis on teaching clinical reasoning skills in many medical schools and residency programs has declined in recent years, 1-6 and several national trends in the current health care environment may be responsible: mounting economic pressures have pushed many health systems and providers to increase clinical productivity and efficiency, 6-11 widespread adoption of electronic health records has increased time spent interfacing with computers instead of patients, 12-14 and a climate has developed in medical schools emphasizing the achievement of high United States Medical Licensing Examination (USMLE) Step scores 15 —all of which have come at the cost of sacrificing time dedicated to teaching clinical skills and diagnostic reasoning. 15-17…”