To the Editor The article by Valikodath et al1 showcases a problem with modern health records: documentation does not always match the patient’s concerns. The authors conclude that electronic medical record data may not provide a comprehensive resource for clinical practice or “big data” research.
I agree that a solution may come from patient-generated information. In a previous report,2 patients were invited to complete a replica of a history as defined by the Centers for Medicare and Medicaid Services. Patients completed a 3-page prehistory form with approximately 30 questions in a structured format that included chief complaint(s), a history of present illness, the status of chronic condition(s), a review of systems, and a past family social history.3
Warner MJ. Patient Coauthored History Could Improve Health Record Accuracy. JAMA Ophthalmol. 2017;135(7):818. doi:10.1001/jamaophthalmol.2017.1637
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