Comparing patient questionnaires and physician documentation in a tertiary hospital setting: A retrospective analysis of subjective information

Patient perception is crucial for medical decision-making. However, discrepancies often arise between patients’ reports and physician documentation. This study aims to examine differences in subjective information between patient questionnaires and physician records in a tertiary hospital setting to provide insights for the development of clinical documentation tools. We retrospectively analyzed 500 paired patient questionnaires and corresponding physician records from five departments at Kyoto University Hospital. Subjective information from the History of Present Illness (HPI) was manually extracted. AI-assisted comparison identified discrepancies, with outputs reviewed by trained researchers. Discrepancies were graded by severity and examined for symptom characteristics and documentation patterns. Logistic regression assessed associations between discrepancy and patient demographics, department, and additional content indicators, with results expressed as odds ratios (OR) and 95% confidence intervals (CI). HPI-related subjective information appeared in 72.8% of patient questionnaires and 80.6% of physician records. However, 48.6% of physician records missed portions of patient-reported information, while 70.8% included additional information absent from questionnaires. Physicians frequently omitted details particularly in onset, quality, severity, and modifying factors. Vague symptoms were more likely to be omitted. Documentation practices varied across departments. Record alignment improved when the patients themselves referenced investigations or referrals. Discrepancies between patient-reported and physician-documented subjective information are common and may affect diagnostic accuracy and care continuity. Enhancing patient questionnaires, supporting interactive history taking, and preserving original patient expressions may help bridge documentation gaps. These findings support the development of tools and strategies that better integrate patient narratives into clinical documentation.