The ethical problem of false positives: a prospective evaluation of physician reporting in the medical record.
OBJECTIVE
To determine if the medical record might overestimate the quality of care through false, and potentially unethical, documentation by physicians.


METHODS
Prospective trial comparing two methods for measuring the quality of care for four common outpatient conditions: (1) structured reports by standardised patients (SPs) who presented unannounced to the physicians' clinics, and (2) abstraction of the medical records generated during these visits.


METHODS
The general medicine clinics of two veterans affairs medical centres.


METHODS
Twenty randomly selected physicians (10 at each site) from among eligible second and third year internal medicine residents and attending physicians.


METHODS
Explicit criteria were used to score the medical records of physicians and the reports of SPs generated during 160 visits (8 cases x 20 physicians). Individual scoring items were categorised into four domains of clinical performance: history, physical examination, treatment, and diagnosis. To determine the false positive rate, physician entries were classified as false positive (documented in the record but not reported by the SP), false negative, true positive, and true negative.


RESULTS
False positives were identified in the medical record for 6.4% of measured items. The false positive rate was higher for physical examination (0.330) and diagnosis (0.304) than for history (0.166) and treatment (0.082). For individual physician subjects, the false positive rate ranged from 0.098 to 0.397.


CONCLUSIONS
These data indicate that the medical record falsely overestimates the quality of important dimensions of care such as the physical examination. Though it is doubtful that most subjects in our study participated in regular, intentional falsification, we cannot exclude the possibility that false positives were in some instances intentional, and therefore fraudulent, misrepresentations. Further research is needed to explore the questions raised but incompletely answered by this research.
D019985:Benchmarking / Q000379:methods*; D002140:California; D026690:Ethics, Clinical; D004992:Ethics, Medical; D005189:False Positive Reactions; D005568:Forms and Records Control / Q000592:standards*; D006801:Humans; D008499:Medical Records / Q000592:standards*; D016544:Patient Simulation; D011320:Primary Health Care; D011446:Prospective Studies; D019984:Quality Indicators, Health Care; D011787:Quality of Health Care; D012372:ROC Curve
Empirical Approach; Health Care and Public Health