Table 2.
Percentage of Physicians Indicating ‘Yes’ in Confidential Survey of Questionable Hospital Documentation Practices
| Questions About Documentation Practice | You Yourself Engaged In | Observed among colleagues | ||
|---|---|---|---|---|
| Number responding* | % With ‘yes’ response (95% CI) | Number responding* | % With ‘yes’ Response (95% CI) | |
| 1. Wrote the admitting History and Physical Exam on patients without personally obtaining all information that was written in the chart | 1,110 | 33 (33 to 36) | 1003 | 48 (45 to 51) |
| 2. Wrote daily progress notes on patients without personally obtaining all information written in the chart | 1,107 | 24 (22 to 27) | 991 | 41 (38 to 44) |
| 3. Copied observations (signs and symptoms) made by other health care givers as one’s own findings in notes | 1,110 | 22 (20 to 25) | 984 | 39 (36 to 42) |
| 4. Copied laboratory values documented by other health care providers without independently verifying the information | 1,112 | 40 (37 to 43) | 965 | 52 (49 to 56) |
| 5. Wrote notes on patients PRIOR to visitation or examination | 1,115 | 9 (7 to 10) | 965 | 22 (19 to 25) |
| 6. Wrote notes on patients but did not personally see or examine them on the day of documentation | 1,108 | 6 (5 to 8) | 962 | 22 (20 to 25) |
*1,094/1,126 (97%) answered all six questions about themselves;
924/1,126 (82%) answered all six questions about their colleagues