Is this true? Problems with the Past Medical History

Article: http://www.gregoryschmidt.ca/writing/problems-with-past-medical-history-data

---- Summary: “Do not believe anything you read in the patient’s chart - it is full of lies”.

This was the first lesson taught to new medical students by our hospital’s most esteemed diagnostician. I have found this assessment generally to be true - both for paper and electronic medical records. However, in theory, we should be able to remedy this problem with electronic medical records.

This post is written across two parts, Part 1: (i) how do we determine if data in the past medical history is true, (ii) how fake data enters the medical chart, and (iii) in practice, how do clinicians verify the truth of medical data?

Part 2 proposes ways to help verify medical diagnosis.

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