A retrospective cohort study on lifestyle habits of cardiovascular patients: how informative are medical records?

BACKGROUND To evaluate the vigilance of medical specialists as to the lifestyle of their cardiovascular outpatients by comparing lifestyle screening as registered in medical records versus a lifestyle questionnaire (LSQ), a study was carried out at the cardiovascular outpatient clinic of the university hospital of Nijmegen, The Netherlands, between June 2004 and June 2005. METHODS For 209 patients information from medical records on lifestyle habits, physician feedback, and interventions in the past year was compared to data gathered in the last month by a self-report LSQ. RESULTS Doctors register smoking habits most consistently (90.4%), followed by alcohol use (81.8%), physical activity (50.2%), and eating habits (27.3%). Compared to the LSQ, smoking, unhealthy alcohol use, physical activity, and unhealthy eating habits are underreported in medical records by 31, 83, 54 and 97%, respectively. Feedback, advice or referral was documented in 8% for smoking, 3% for alcohol use, 12% for physical activity, and 26% for eating habits. CONCLUSION Lifestyle is insufficiently registered or recognized by doctors providing routine care in a cardiovascular outpatient setting. Of the unhealthy lifestyle habits that are registered, few are accompanied by notes on advice or intervention. A lifestyle questionnaire facilitates screening and interventions in target patients and should therefore be incorporated in the cardiovascular setting as a routine patient intake procedure.