How accurate is the medical record? A comparison of the physician's note with a concealed audio recording in unannounced standardized patient encounters
How accurate is the medical record? A comparison of the physician's note with a concealed audio recording in unannounced standardized patient encounters
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DOI：
10.1093/jamia/ocaa027
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发表时间：
2020-05-01
影响因子：
6.4
通讯作者：
Schwartz, Alan
中科院分区：
文献类型：
--
作者：
Weiner, Saul J.;Wang, Shiyuan;Schwartz, Alan
目的：病历中的准确记录对于高质量的护理至关重要;报销需要大量的记录。有时候，这两个必要条件会发生冲突。我们探讨了一致性的信息记录在医疗记录与金标准measure.Materials和方法：我们比较了105个遇到笔记的音频记录秘密收集的未经宣布的标准化病人从36名医生，以确定差异和估计报销的影响，计费的基础上访问的说明与实际提供的护理。结果：共有636个文档错误，其中包括181个未发生的图表调查结果和455个未绘制的调查结果。90%的笔记至少包含一个错误。在21个案例中，该说明证明收费水平高于黄金标准录音，在4个案例中，该说明低估了服务水平（P = .005），导致40个4级音符，而不是基于音频的23个合理音符，74%的夸大错误陈述。虽然人们不能根据退伍军人事务部卫生系统内相对较小的医生样本来概括具体的错误率，的规模的调查结果提出了根本性的关注的完整性，目前的医疗记录文件的过程中，作为一个实际的代表性的照顾，与影响，以确定质量和资源utilization.Conclusion：医疗记录不应该被假定为反映提供的照顾。此外，委托错误-记录实际提供的服务-可能夸大资源利用的估计数。
Objectives: Accurate documentation in the medical record is essential for quality care; extensive documentation is required for reimbursement. At times, these 2 imperatives conflict. We explored the concordance of information documented in the medical record with a gold standard measure.Materials and Methods: We compared 105 encounter notes to audio recordings covertly collected by unannounced standardized patients from 36 physicians, to identify discrepancies and estimate the reimbursement implications of billing the visit based on the note vs the care actually delivered.Results: There were 636 documentation errors, including 181 charted findings that did not take place, and 455 findings that were not charted. Ninety percent of notes contained at least 1 error. In 21 instances, the note justified a higher billing level than the gold standard audio recording, and in 4, it underrepresented the level of service (P = .005), resulting in 40 level 4 notes instead of the 23 justified based on the audio, a 74% inflated misrepresentation.Discussion: While one cannot generalize about specific error rates based on a relatively small sample of physicians exclusively within the Department of Veterans Affairs Health System, the magnitude of the findings raise fundamental concerns about the integrity of the current medical record documentation process as an actual representation of care, with implications for determining both quality and resource utilization.Conclusion: The medical record should not be assumed to reflect care delivered. Furthermore, errors of commission-documentation of services not actually provided-may inflate estimates of resource utilization.