Table 1.
Percentages of complete documentation in each section of simulated charts
| Section | Complete (%) |
|---|---|
| History of present illness | |
| Location | 103 (100%) |
| Quality | 67 (64.4%) |
| Severity | 91 (87.5%) |
| Duration | 72 (69.2%) |
| Timing | 53 (50.1%) |
| Context | 22 (21.1%) |
| Modifying factors | 43 (41.3%) |
| Associated signs and symptoms | 5 (4.8%) |
| Review of systems | |
| Problem Focused (0) | 8 (7.6%) |
| Expanded Problem (1) | 14 (13.4%) |
| Detailed (2–9) | 81 (77.8%) |
| Comprehensive (≥10) | 0 (0%) |
| Past medical, family, social history | |
| Past Medical History | 82 (78.8%) |
| Family History | 2 (1.9%) |
| Social History | 20 (19.2%) |
| Physical exam | |
| Limited exam of affected Body Area or Organ System (1) | 8 (7.6%) |
| Limited exam of affected Body Area(s) and other related organ system (2–4) | 44 (42.3%) |
| Extended exam of Body Area(s) and other symptomatic related Organ System(s) (5–7) | 41 (39.7%) |
| General multi-system exam or complete single Organ System exam (≥8) | 10 (9.6%) |