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How accurate is the medical record? A comparison of the physician’s note with a concealed audio recording in unannounced standardized patient encounters

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 A...

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Bibliografiske detaljer
Udgivet i:J Am Med Inform Assoc
Main Authors: Weiner, Saul J, Wang, Shiyuan, Kelly, Brendan, Sharma, Gunjan, Schwartz, Alan
Format: Artigo
Sprog:Inglês
Udgivet: Oxford University Press 2020
Fag:
Online adgang:https://ncbi.nlm.nih.gov/pmc/articles/PMC7647276/
https://ncbi.nlm.nih.gov/pubmed/32330258
https://ncbi.nlm.nih.govhttp://dx.doi.org/10.1093/jamia/ocaa027
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