{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,16]],"date-time":"2026-06-16T16:32:22Z","timestamp":1781627542614,"version":"3.54.5"},"reference-count":15,"publisher":"Oxford University Press (OUP)","issue":"5","license":[{"start":{"date-parts":[[2020,4,24]],"date-time":"2020-04-24T00:00:00Z","timestamp":1587686400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/academic.oup.com\/journals\/pages\/open_access\/funder_policies\/chorus\/standard_publication_model"}],"funder":[{"DOI":"10.13039\/100000738","name":"Department of Veterans Affairs","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100000738","id-type":"DOI","asserted-by":"publisher"}]},{"name":"Health Services Research & Development","award":["IIR 04-107-2"],"award-info":[{"award-number":["IIR 04-107-2"]}]},{"DOI":"10.13039\/100010443","name":"University of Illinois","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100010443","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2020,5,1]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:sec><jats:title>Objectives<\/jats:title><jats:p>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.<\/jats:p><\/jats:sec><jats:sec><jats:title>Materials and Methods<\/jats:title><jats:p>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.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>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.<\/jats:p><\/jats:sec><jats:sec><jats:title>Discussion<\/jats:title><jats:p>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.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>The medical record should not be assumed to reflect care delivered. Furthermore, errors of commission\u2014documentation of services not actually provided\u2014may inflate estimates of resource utilization.<\/jats:p><\/jats:sec>","DOI":"10.1093\/jamia\/ocaa027","type":"journal-article","created":{"date-parts":[[2020,2,29]],"date-time":"2020-02-29T20:15:59Z","timestamp":1583007359000},"page":"770-775","source":"Crossref","is-referenced-by-count":78,"title":["How accurate is the medical record? A comparison of the physician\u2019s note with a concealed audio recording in unannounced standardized patient encounters"],"prefix":"10.1093","volume":"27","author":[{"given":"Saul J","family":"Weiner","sequence":"first","affiliation":[{"name":"Jesse Brown VA Medical Center, Center of Innovation for Complex Chronic Healthcare, Chicago, Illinois, USA"},{"name":"Department of Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shiyuan","family":"Wang","sequence":"additional","affiliation":[{"name":"College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Brendan","family":"Kelly","sequence":"additional","affiliation":[{"name":"Jesse Brown VA Medical Center, Center of Innovation for Complex Chronic Healthcare, Chicago, Illinois, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gunjan","family":"Sharma","sequence":"additional","affiliation":[{"name":"Jesse Brown VA Medical Center, Center of Innovation for Complex Chronic Healthcare, Chicago, Illinois, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alan","family":"Schwartz","sequence":"additional","affiliation":[{"name":"Department of Medical Education, College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2020,4,24]]},"reference":[{"issue":"6","key":"2021042400041686900_ocaa027-B1","doi-asserted-by":"crossref","first-page":"509","DOI":"10.1097\/00005650-197111000-00007","article-title":"Problems with medical records","volume":"9","author":"Tufo","year":"1971","journal-title":"Med Care"},{"issue":"3","key":"2021042400041686900_ocaa027-B2","doi-asserted-by":"crossref","first-page":"407","DOI":"10.1542\/peds.56.3.407","article-title":"Validating the content of pediatric outpatient medical records by means of tape-recording doctor-patient encounters","volume":"56","author":"Zuckerman","year":"1975","journal-title":"Pediatrics"},{"issue":"3","key":"2021042400041686900_ocaa027-B3","doi-asserted-by":"crossref","first-page":"310","DOI":"10.1097\/00005650-198103000-00006","article-title":"The validity of the medical record","volume":"19","author":"Romm","year":"1981","journal-title":"Med Care"},{"key":"2021042400041686900_ocaa027-B4","author":"Nicholas"},{"issue":"5","key":"2021042400041686900_ocaa027-B5","doi-asserted-by":"crossref","first-page":"291","DOI":"10.1136\/jme.28.5.291","article-title":"The ethical problem of false positives: a prospective evaluation of physician reporting in the medical record","volume":"28","author":"Dresselhaus","year":"2002","journal-title":"J Med Ethics"},{"issue":"6","key":"2021042400041686900_ocaa027-B6","doi-asserted-by":"crossref","first-page":"2290","DOI":"10.1111\/j.1475-6773.2006.00560.x","article-title":"Caught in the act? Prevalence, predictors, and consequences of physician detection of unannounced standardized patients","volume":"41","author":"Franz","year":"2006","journal-title":"Health Serv Res"},{"issue":"7366","key":"2021042400041686900_ocaa027-B7","doi-asserted-by":"crossref","first-page":"679","DOI":"10.1136\/bmj.325.7366.679","article-title":"Using standardised patients to measure physicians\u2019 practice: validation study using audio recordings","volume":"325","author":"Luck","year":"2002","journal-title":"BMJ"},{"issue":"2","key":"2021042400041686900_ocaa027-B8","doi-asserted-by":"crossref","first-page":"69","DOI":"10.7326\/0003-4819-153-2-201007200-00002","article-title":"Contextual errors and failures in individualizing patient care: a multicenter study","volume":"153","author":"Weiner","year":"2010","journal-title":"Ann Intern Med"},{"key":"2021042400041686900_ocaa027-B9"},{"key":"2021042400041686900_ocaa027-B10"},{"issue":"5","key":"2021042400041686900_ocaa027-B11","doi-asserted-by":"crossref","first-page":"657","DOI":"10.1097\/ACM.0000000000001017","article-title":"Contextual errors in medical decision making: overlooked and understudied","volume":"91","author":"Weiner","year":"2016","journal-title":"Acad Med"},{"key":"2021042400041686900_ocaa027-B12","first-page":"269","article-title":"Are electronic medical records trustworthy? 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