Sharma, R., Kostis, W.J., Wilson, A.C. et al. J GEN INTERN MED (2008) 23: 1865. doi:10.1007/s11606-008-0750-6
Physicians, influenced by various pressures, may document information in patient records that they did not personally observe.
To evaluate the hospital chart documentation practices of internists and internal medicine sub-specialists in the Northeastern United States.
An anonymous mail survey questionnaire.
One thousand one hundred twenty-six randomly selected internists and internal medicine sub-specialists.
Responses to questions describing their own hospital chart documentation practices, those they observed among their colleagues, and ratings of the importance of possible influences.
Response rate was 43%. Fifty-nine percent (59%) of physicians reported personally engaging in one or more of six questionable documentation scenarios. Forty percent (40%, CI; 37%-43%) indicated that they recorded laboratory notes in patient records based on information that they did not personally obtain, while 6% (CI; 5%-8%) admitted to writing notes on patients not personally seen or examined. The corresponding percentages reported for their colleagues were 52% (CI; 49%-56%) and 22% (CI; 20%-25%), respectively. Increased rates of documentation lapses were significantly associated with working directly with residents and/or fellows (OR = 1.71, CI; 1.30–2.25), younger age (OR for 10 year age decrease = 1.35, CI; 1.19–1.53), white race (OR = 1.47, CI; 1.08–2.00), and graduation from US medical schools (OR = 1.75, CI; 1.31–2.34).
Most physicians report having engaged in questionable hospital chart documentation. This practice is more common among physicians who are younger, working with house staff, and graduates of US medical schools.