What does poor historian mean

There are also other situations where patients are technically intentionally lying, but for completely understandable reasons: victims of interpersonal violence who fear retribution; patients who fear that medical information may be relayed intentionally or otherwise to law enforcement or other authorities. Or they are afraid their physician is going to judge them for some of their private behaviors, many of which carry societal stigma.

The second category is a whole different ball of wax. Okwerekwu mentions a patient who had reported they had never had surgery before, embarrassing her on rounds when the team saw an obvious thoracotomy scar. Some patients also see their treated medical issues as no longer problems. There are multiple factors at play here.

Patients did not go to school for years to learn about their medical problems. Patients have not been trained on how to talk to doctors. When a provider is unable to obtain certain medical information, he or she should clearly document in the record:.

Before giving up the ship, however, the provider should attempt to obtain the information from another source, such as a family member, spouse, medical record, etc. If these sources were unable to supply the missing information, the attempt should be documented as well. For example:. If, at a later time, the patient or some other source is able to supply the missing information, the provider may add an addendum to the record to fill in the missing blanks that support medical necessity for the provided services.

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