Should doctors stop taking the generic history? A comparison of house officers' and nursing staff clerking in general surgery

The purpose of this paper is to show how the implementation of the European Working Time Directive in August 2004 has dramatically decreased junior doctors' working hours, as a consequence of which new ways of working will need to be found. Traditionally both doctors and nurses record the same generic history (past medical history, social and family history, drug history and allergies) in their own notes. This is unnecessary duplication and maybe only nursing staff should record this information. This study is undertaken to identify the differences between junior doctors' and nurses' clerking to assess whether they are comparable. A prospective study of 100 case notes from elective and emergency admissions was undertaken. The completeness of various parts of the history and the recording of the vital signs were compared between nurses and house officers. The Past Medical History was complete in only 30 per cent of the house officers' notes and 42 per cent of nursing records. The social history was complete in all the nursing records but only 35 per cent of the doctors' notes. Nurses recorded a complete personal history more than doctors (62 per cent v. 13 per cent respectively). The drug history was poorly recorded in house officers' notes, being complete in 22 per cent, whereas this was complete in 73 per cent of nursing records. The record of the history of allergies was poor in both groups at just over 10 per cent. Finally 87 per cent of nurses managed to record vital signs but these were missing from nearly half of the house officers' notes. The study has shown that details of the generic medical history are recorded more completely by the nursing staff and only they should record this information. This will allow junior doctors more time to deal with the increased demands and reduced hours of work.