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Related Experiment Videos

Hospital charting of substance use.

T G Graves1, G T Terlep, D R Rudy

  • 1Bay Area Family Physicians, New Baltimore, Mich.

Family Medicine
|November 1, 1992
PubMed
Summary

Physicians frequently document cigarette and alcohol use but rarely illicit drug use. Documentation varies by medical specialty, career stage, and patient sex, impacting substance abuse care.

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Area of Science:

  • Medical Practice
  • Substance Abuse Research

Background:

  • Physicians play a role in helping patients reduce substance use.
  • Inquiring about substance use is a prerequisite for intervention.

Purpose of the Study:

  • To assess physicians' documentation of patient substance use (alcohol, cigarettes, illicit drugs).
  • To compare documentation rates between residents and attending physicians, and across family practice and internal medicine specialties.

Main Methods:

  • Retrospective review of 212 inpatient medical records.
  • Analysis of documentation frequency for alcohol, cigarette, and illicit drug use.
  • Comparison of charting practices based on physician level, specialty, and patient demographics.

Main Results:

  • Cigarette use was charted in 73%, alcohol in 70%, and illicit drugs in only 12.5% of records.
  • Family physicians documented substance use more often than internal medicine physicians.
  • Residents charted substance use more frequently than attending physicians.
  • Attending family physicians documented substance use more in male than female patients.

Conclusions:

  • Physician career stage, specialty, and patient sex influence substance abuse charting frequency.
  • These factors may impact the consistency of substance abuse screening and intervention.

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