title: 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.
  
  
  METHODS
  An anonymous mail survey questionnaire.
  
  
  METHODS
  One thousand one hundred twenty-six randomly selected internists and internal medicine sub-specialists.
  
  
  METHODS
  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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ 08903-0019, USA. sharmar1@umdnj.edu
authors.forename: Ranita
authors.initials: R
authors.lastname: Sharma
authors.forename: William J
authors.initials: WJ
authors.lastname: Kostis
authors.forename: Alan C
authors.initials: AC
authors.lastname: Wilson
authors.forename: Nora M
authors.initials: NM
authors.lastname: Cosgrove
authors.forename: Afton L
authors.initials: AL
authors.lastname: Hassett
authors.forename: Abel E
authors.initials: AE
authors.lastname: Moreyra
authors.forename: Cristine D
authors.initials: CD
authors.lastname: Delnevo
authors.forename: John B
authors.initials: JB
authors.lastname: Kostis