Questionable hospital chart documentation practices by physicians

Abstract

Background: Physicians, influenced by various pressures, may document information in patient records that they did not personally observe.

Objective: To evaluate the hospital chart documentation practices of internists and internal medicine sub-specialists in the Northeastern United States.

Design: An anonymous mail survey questionnaire.

Participants: One thousand one hundred twenty-six randomly selected internists and internal medicine sub-specialists.

Measurements: Responses to questions describing their own hospital chart documentation practices, those they observed among their colleagues, and ratings of the importance of possible influences.

Results: 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).

Conclusion: 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.