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.

We compared 105 encounter notes to audio recordings covertly collected by unannounced standardized patients from 36 physicians, to identify discrepancies and estimate the reimbursement implications of billing the visit based on the note vs the care actually delivered.

There were 636 documentation errors, including 181 charted findings that did not take place, and 455 findings that were not charted. Ninety percent of notes contained at least 1 error. In 21 instances, the note justified a higher billing level than the gold standard audio recording, and in 4, it underrepresented the level of service (P = .005), resulting in 40 level 4 notes instead of the 23 justified based on the audio, a 74% inflated misrepresentation.