Internists' perceptions and performance in office practice

Thirty-one internists in private practice chose items of care that they considered essential and likely to be recorded in the evaluation and management of diabetics, hypertensives, women with symptoms of dysuria or frequency, and patients requesting a general examination. Records of patients with these conditions, in those practices, were reviewed to determine which items of care were routinely performed and recorded. Overall, physical examination and laboratory evaluation items were more likely both to be considered essential and to be recorded than were history questions or management instructions. The lists of cure criteria and frequently performed components of the care process are presented for use by other peer review groups and for the interest of other practicing internists.