What's in a physician's note is not necessarily related to the outcome of that physician's care, according to research in the British Medical Journal of Quality and Safety.
Researchers reviewed 239 notes on patients with diabetes mellitus or coronary artery disease from 111 physicians, documenting the presence of various items in the notes with a nine-item checklist.
Several items were often missing from the notes, including reason for visit (10 percent), medication list (19. percent) and follow-up appointment information (18 percent).
Clinical outcomes for these patients were not correlated with the information physicians recorded or didn't record in their notes.
The study concluded that while poorly written notes do not indicate bad care, well-written notes to not necessarily indicate good care. The authors noted individual physicians documented similar information in different locations within the electronic health record.
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