More than half of the physicians in this study reported engaging in some questionable hospital chart documentation practices. Many of the physicians reported using charting practices that would be considered unacceptable (e.g. charting prior to seeing the patient or without seeing the patient on the day of charting). We found an increased rate of these charting practices among physicians on resident-run services. The most commonly reported questionable documentation practices (e.g. copying labs) were considered the least serious by a separate external panel of senior practitioners. However, all such documentation practices can have negative implications for patient care and may increase the likelihood of medical errors.16
The primary objective of maintaining a medical record is to accurately document data and events during hospitalization, and to facilitate communication among health care providers. Inaccurate information related to current or past diagnoses and therapeutics is likely to be propagated if independent and repeated verification fails to occur. Only 19% of physicians we surveyed reported the use of the electronic medical record, but use of such systems will likely increase dramatically over the next several years. Although we did not find the use of an electronic medical record system to be a significant predictor of questionable documentation practices, possibly because of the low current prevalence of its use, we are concerned that the ease of the “copy-and-paste” command will further perpetuate documentation inaccuracies and promote greater reliance on the physician or healthcare professional who recorded the first entry.6
The pressures that may influence physicians to engage in questionable documentation practices are numerous, including reimbursement regulations, time-constraints, fear of litigation, and quality audits. The demand for documentation for insurance payment was the subject of an editorial describing the disagreement over escalating complexities for reporting data.17
Healthcare professionals may regard insurance related billing requirements as increasingly onerous and irrelevant to clinical practice, leading to “treating the chart” and not the patient. We found that belief in good medical practice (patient-centered care) was significantly related with low frequency of questionable documentation practices. In contrast, fear of litigation and the threat of malpractice liability have been cited as reasons why physicians alter their clinical behavior and practice defensive medicine.18
Our data were derived from self-reported questionnaires, and are thus limited by various forms of bias. Despite rigorous steps taken to maintain participant anonymity, social desirability bias still likely influenced the results.19,20
The desire to present a positive impression of oneself can contribute to minimizing instances of questionable chart documentation or choosing not to participate in the study; thus the true frequency of questionable documentation practices is likely underestimated in this study. In contrast, the rates of questionable charting practices were reported to be much higher in respondents’ colleagues than among the respondents themselves. These rates could be inflated due to the tendency to overestimate the universality of one’s behaviors as a means to overcome the cognitive dissonance associated with engaging in deviant behavior.21,22
Further, the tendency to exaggerate the deviant behavior of others is amplified in restrictive communities, such as those found in hospital settings.23
Our data support these observations, for in up to 87% of cases where a transgression was self-reported, the same transgression was “observed in others.” In addition, physicians have many colleagues, and it is conceivable that only one of these colleagues was observed engaging in the questionable behaviors. Thus, rates related to the observation of the questionable chart documentation of others may be inflated.
Our findings may not be generalizable to national medical practice since the behaviors are self-reported and peer-reported by internists from the Northeast region. However, the large number of respondents representing a wide range of ages, levels of experience and specialties; adequate response rate; and the consistency of the results support the validity of our findings. The high average age of our respondents may also limit the generalizability of these results.
Another limitation of our study is related to the instrument itself. Although the items were found by a local panel of physicians to have good face validity, there are no other instruments or studies for comparison to further assess validity. Although our response rate was below 50%, it is consistent with other studies requesting self-reports of undesirable behavior. Future studies are needed to confirm these results and should further examine the frequency of engaging in questionable charting practices and the estimated percentage of others observed engaging in the same behavior. Another important ethical issue is whether or not physicians who observed these behaviors among others confronted their colleagues.
In conclusion, we found a significant proportion of physicians surveyed admitted to having engaged in questionable chart documentation practices. This finding was more common among younger physicians who are graduates of US medical schools, and those who work with residents and/or fellows. We speculate that this finding is a direct result of behavior modeling that occurs in the current US graduate and postgraduate medical education environment. Physicians are taught documentation practices early in training, but actual charting behaviors are more likely modeled from observations made in the clinical setting. Electronic data reporting and retrieval, expansion of documentation guideline requirements for billing and coding, and an increasingly litigious environment have all adversely influenced documentation. Such questionable documentation practices are likely to impact patient care adversely. Clinician educators and other senior staff should be acutely aware of the need to create a training culture and environment conducive to appropriate ethical behaviors and, more specifically, emphasize the importance of accurate chart documentation.