How Incomplete Patient Assessments Lead to Harm & Medical Malpractice

EvaluCare
May 25
7 min read

History and physical assessments in healthcare are the bedrock of safe care. Incomplete or problematic H&Ps are contributing factors to errors, that can lead to medical malpractice.

The Foundational Role of History and Physicals in Safe Medical Care

In the complex world of healthcare, the history and physical (H&P) examination is the initial assessment that is bedrock of safe, effective, and patient-centered care. It is the most basic yet critical step in the diagnostic process. Collecting a comprehensive medical history and conducting a thorough physical exam are not simply formalities, they are essential clinical tools. When this step is skipped, rushed, or inadequately performed, it can trigger a cascade of missteps that culminate in serious patient harm.

The impact of a missed or poorly documented history and physical is wide-ranging. Patients may receive incorrect diagnoses, be prescribed medications that interact dangerously with existing prescriptions, or undergo procedures that could have been avoided altogether. Malpractice lawsuits frequently cite failure to obtain or consider a patient’s full medical history as a key factor in avoidable harm. According to the National Practitioner Data Bank, failure in history-taking and physical assessment ranks among the top contributing factors in medical malpractice cases.

Why Do Providers Struggle to Take Comprehensive Histories?

Despite its importance, clinicians frequently report challenges in obtaining full histories and performing detailed physical exams. Some of the common reasons include:

Time Constraints: Physicians, particularly in busy emergency departments or primary care clinics, are often pressured to see more patients in less time. This may lead to shortcuts in history-taking.
Electronic Health Record (EHR) Fatigue: While EHRs can streamline documentation, they also introduce "note bloat" and make it harder to filter meaningful data from noise. Providers may miss critical information buried in lengthy, templated notes.
Copy Forward: Related to the two above copying forward data can lead to inaccurate or incomplete current clinical information being acted on.
Fragmented Care: In today’s healthcare system, patients may see multiple specialists, leading to gaps in information if care is not well-coordinated. Clinicians may not have access to previous records or may overlook asking for key details.
Language Barriers and Communication Gaps: Providers may not have access to medical interpreters or may rush interactions, leading to miscommunication or omission of essential medical details.
Cognitive Biases: Clinicians, like all humans, are susceptible to biases that can cloud judgment. One of the most harmful is confirmation bias, where providers latch onto an initial diagnosis and discount evidence that contradicts it, including history and physical details.

When Errors Occur: Case Examples of Medical Malpractice Due to Incomplete H&P

1. Missed Cardiac History Leads to Fatal Heart Attack

A 52-year-old man with a history of high blood pressure and smoking visited an urgent care clinic with intermittent chest discomfort. The attending provider, overwhelmed by a packed waiting room, conducted a minimal history, attributing the pain to reflux without ordering cardiac tests. The man died of a heart attack two days later. A malpractice suit revealed that a more detailed history would have flagged the risk and led to life-saving intervention. The case settled for $1.1 million.

2. Failure to Document Allergy Results in Drug Reaction

In a busy ER, a 34-year-old woman presented with a urinary tract infection. The attending physician prescribed trimethoprim-sulfamethoxazole without reviewing her past records. She had a documented sulfa allergy, which was missed. She developed Stevens-Johnson syndrome, a rare, life-threatening skin reaction. The case resulted in a settlement of $700,000.

3. Overlooking Past Stroke History Delays Life-Saving Care

A 68-year-old patient presented with slurred speech and weakness. The provider, assuming it was a new stroke, failed to ask about previous stroke events. It turned out the patient had suffered a similar episode a month earlier but had discontinued blood thinners on his own. By the time this came to light, it was too late for intervention. The delay led to permanent disability and a $450,000 settlement.

Categories of Errors Resulting from Inadequate H&P

A. Medication-Related Errors

Missed Allergies: Prescribing drugs that trigger known allergic reactions.
Inappropriate Dosing: Not adjusting for renal or liver dysfunction noted in medical history.
Drug Interactions: Ignoring ongoing medications that may conflict with new prescriptions.

B. Diagnostic Failures

Misdiagnosis: Mistaking heartburn for angina due to lack of cardiac history.
Delayed Diagnoses: Missing signs of cancer when a family history isn't elicited.

C. Surgical Complications

Unnecessary Surgery: Operating without recognizing non-surgical treatment history or other contraindications.
Failure to Identify Risks: Not uncovering clotting disorders or bleeding risks before surgery.

The Problem of Bias in Clinical Judgment

Cognitive Biases and How They Lead to Patient Harm

Confirmation Bias is one of the most dangerous cognitive traps in medicine. It occurs when providers anchor on an initial diagnosis and seek information to support it, while ignoring contradictory evidence. This is especially harmful when compounded by incomplete histories.

Example 1:

A patient arrives with shortness of breath and chest pain. The physician assumes anxiety due to a psychiatric history. Because no cardiac history is taken, the patient is not evaluated for a pulmonary embolism and dies hours later.

Example 2:

An elderly patient falls and complains of back pain. The provider assumes it's musculoskeletal due to osteoporosis. No neurological exam is conducted. The patient has a spinal cord injury that is missed, leading to permanent paralysis.

How Patients & Families Can Protect Themselves

Bring Records/History Patients and families can play a role by being proactive: bring a written medical history, ask providers if they’ve reviewed it, and don’t hesitate to speak up if something seems overlooked.

In addition, prepare a detailed list of current medications, past surgeries, chronic conditions, allergies, and family medical history before any medical appointment or hospital admission. Ask for a medication reconciliation, if you feel medications need further review.

Include important lifestyle information such as smoking, alcohol use, and recent travel, which may influence diagnosis and treatment. If the patient has a complex history, organize it chronologically or by body system to make it easier for providers to digest quickly.

Confirm & EncourageDuring the visit, actively confirm that your healthcare team has reviewed your history by asking, ‘Do you have everything you need from my medical background to make this decision?’ or ‘Did you see my last cardiology note?’ Encourage providers to double-check EHR entries and clarify anything that seems incomplete or outdated.

Bring/Be a Patient AdvocateBring another family member or caregiver to appointments to help recall important information and ask questions. Don’t be afraid to reiterate or reframe key points if they’re not being acknowledged. If a provider rushes through the history or doesn’t perform a physical exam, respectfully ask, ‘Would it help to review a bit more of the background before we move forward?’ or ‘Could we go over what you've found in the exam so far?’

Continue to DocumentMost importantly, document your interactions. Keep a care journal, take notes during visits, and follow up in writing using secure messaging portals when needed. Request access to your electronic medical record to verify accuracy and completeness. Get access to your family member’s health record to review communications and support care delivery. If errors or omissions are found, notify the provider’s office or care team immediately to correct the record.

These simple but strategic steps empower patients and families to become active partners in care, helping to ensure that medical decisions are based on a full, accurate understanding of the patient’s health history, ultimately reducing the risk of misdiagnosis or inappropriate treatment."

How EvaluCare Reviews Help Identify Failures in H&P

When medical harm occurs, it’s not always easy for patients or even attorneys to determine what went wrong. That’s where EvaluCare comes in.

EvaluCare’s team of expert medical and quality professionals specializes in reviewing medical records and case documentation to determine whether:

A thorough history and physical were taken
Standard protocols were followed
Diagnoses and treatment decisions aligned with clinical guidelines
Bias or system-level issues contributed to the error

By applying clinical acumen and quality standards gained from working in the field for decades as healthcare system leaders, the EvaluCare team can help determine whether failure to take a complete history or perform a physical examination was a causal or contributing factor to patient harm. This can be crucial in building or refuting a medical malpractice claim.

Real Settlements That Illustrate the Impact

$1.5 Million: Awarded to a patient who developed sepsis after providers failed to recognize an undiagnosed urinary tract infection because a full symptom history was not taken.
$950,000: Settlement for a patient whose diabetes was overlooked due to the absence of documented history, resulting in delayed wound healing and amputation.
$2.2 Million: For a child with a congenital heart defect that went undiagnosed because providers dismissed the mother’s report of family history and symptoms.

Conclusion: Why Every History Matters

Failure to conduct a comprehensive history and physical examination is a serious lapse, one that continues to result in medical malpractice claims, preventable harm, and lost lives. Time pressures, fragmented care, and cognitive biases all contribute to these mistakes. However, these are not excuses, they are problems that need addressing.

Patients and families can play a role by being proactive: bring a written medical history, ask providers if they’ve reviewed it, and don’t hesitate to speak up if something seems overlooked.

And if harm has already occurred?

EvaluCare is here to help. Our experts understand how medical decisions are made, how errors unfold, and how failures in H&P can derail entire treatment courses. We help families uncover the truth and determine if the care received met accepted clinical standards.

Learn more at www.EvaluCare.net or email info@EvaluCare.net