How accurate is the medical record? A comparison of the physician’s note with a concealed audio recording in unannounced standardized patient encounters. Weiner, S. J, Wang, S., Kelly, B., Sharma, G., & Schwartz, A. Journal of the American Medical Informatics Association, 27(5):770–775, May, 2020.
How accurate is the medical record? A comparison of the physician’s note with a concealed audio recording in unannounced standardized patient encounters [link]Paper  doi  abstract   bibtex   
Abstract 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.
@article{weiner_how_2020,
	title = {How accurate is the medical record? {A} comparison of the physician’s note with a concealed audio recording in unannounced standardized patient encounters},
	volume = {27},
	issn = {1527-974X},
	shorttitle = {How accurate is the medical record?},
	url = {https://academic.oup.com/jamia/article/27/5/770/5824779},
	doi = {10.1093/jamia/ocaa027},
	abstract = {Abstract
            
              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.},
	language = {en},
	number = {5},
	urldate = {2020-07-13},
	journal = {Journal of the American Medical Informatics Association},
	author = {Weiner, Saul J and Wang, Shiyuan and Kelly, Brendan and Sharma, Gunjan and Schwartz, Alan},
	month = may,
	year = {2020},
	pages = {770--775},
}

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