title: Hospital charting of substance use.
abstract: BACKGROUND
  Recent evidence suggests that physicians can help patients reduce or even discontinue cigarette smoking. Physicians may also be able to help patients decrease their use of alcohol or illegal drugs. A prerequisite for helping patients decrease substance use is for physicians to ask patients about their use of cigarettes, alcohol, and illicit drugs.
  
  
  METHODS
  We performed a retrospective study of 212 medical records to measure physicians' documentation of patient use of alcohol, cigarettes, and illicit drugs in an inpatient setting. The study compared residents and attending physicians in family practice and internal medicine.
  
  
  RESULTS
  Physicians charted cigarette use in 73% of medical records, alcohol use in 70%, and drug use in only 12.5%. Family physicians charted substance use more frequently than internal medicine physicians for alcohol and illicit drugs (P < .05 by Pearson's chi-square analysis) and for cigarettes (P = .07). In each specialty, residents charted substance use more often than attending physicians (P < .01). Attending family physicians (P < .05) charted substance use more often in male than in female patients. This was not found among internal medicine physicians.
  
  
  CONCLUSIONS
  The results of the study suggest that the stage of medical career, medical specialty, and sex of the patient affect the frequency of charting substance abuse.
authors.affiliation: Bay Area Family Physicians, New Baltimore, Mich.
authors.forename: T G
authors.initials: TG
authors.lastname: Graves
authors.forename: G T
authors.initials: GT
authors.lastname: Terlep
authors.forename: D R
authors.initials: DR
authors.lastname: Rudy
authors.forename: M K
authors.initials: MK
authors.lastname: Burge
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000428:Alcohol Drinking; D004282:Documentation; D005194:Family Practice; D005260:Female; D006801:Humans; D007297:Inpatients; D007388:Internal Medicine; D007396:Internship and Residency; D008297:Male; D008499:Medical Records; D008875:Middle Aged; D012189:Retrospective Studies; D012907:Smoking; D019966:Substance-Related Disorders / Q000175:diagnosis*