Clinical annotation of tobacco use in patient charts at Indian Health Service clinics and hospitals.
Few clinicians would doubt the importance of obtaining smoking histories from their patients. Nevertheless a clinicians' practices of documenting tobacco use in medical records varies substantially among individual providers and between different health care systems. To investigate the chart documentation of patient smoking among Indian Health Service clinicians, we reviewed 545 randomly selected patient records from 22 different Indian Health Service affiliated clinics. We focused on differences in charting of tobacco use by type of clinic and by geographic area within the Indian Health Service. Documentation varied by area, ranging from no documentation in the Albuquerque, Navajo, and Phoenix areas to 51% in the Oklahoma area. We conclude that clinicians practices of documentation of tobacco use vary widely and recommend that this practice be more widely encouraged at all affiliated Indian Health Service clinics.
IHS Hdqtrs West, Cancer Prevention and Control Program, Albuquerque, NM 87110, USA.
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D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002675:Child, Preschool; D004282:Documentation / Q000592:standards*; D005260:Female; D006801:Humans; D007198:Indians, North American; D007223:Infant; D008297:Male; D008485:Medical Audit; D008487:Medical History Taking; D008499:Medical Records / Q000592:standards*; D008875:Middle Aged; D012111:Residence Characteristics; D012907:Smoking / Q000208:ethnology*; D014481:United States; D016549:United States Indian Health Service