Failure to document.

Abstract

The failure to adequately document events in the written clinical record is the major reason for letters of inquiry from Peer Review Organizations (PROs). The major causes of inadequate documentation are time pressures, the mind set of physicians, increasing subspecialization with the fragmentation of patient care, and a distrust of review activities in general. However, the accurate recording of medical events that ensue during the course of caring for patients is an integral aspect of the profession of medicine.