How accurate is the medical record? A comparison of the physician's note with a concealed audio recording in unannounced standardized patient encounters.
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.
Author(s): Weiner, Saul J, Wang, Shiyuan, Kelly, Brendan, Sharma, Gunjan, Schwartz, Alan
DOI: 10.1093/jamia/ocaa027