Hospital charting of substance use

• Published in: Family medicine Vol. 24; no. 8; p. 613
• Main Authors: Graves, T G, Terlep, G T, Rudy, D R, Burge, M K
• Format: Journal Article
• Language: English
• Published: United States 01-11-1992
• Subjects: Adolescent; Adult; Aged; Alcohol Drinking; Documentation; Family Practice; Female; Humans; Inpatients; Internal Medicine; Internship and Residency; Male; Medical Records; Middle Aged; Retrospective Studies; Smoking; Substance-Related Disorders - diagnosis
• ISSN: 0742-3225

Recent evidence suggests that physicians can help patients reduce or even discontinue cigarette smoking. Physicians may also be able to help patients decrease their use of alcohol or illegal drugs. A prerequisite for helping patients decrease substance use is for physicians to ask patients about their use of cigarettes, alcohol, and illicit drugs.
We performed a retrospective study of 212 medical records to measure physicians' documentation of patient use of alcohol, cigarettes, and illicit drugs in an inpatient setting. The study compared residents and attending physicians in family practice and internal medicine.
Physicians charted cigarette use in 73% of medical records, alcohol use in 70%, and drug use in only 12.5%. Family physicians charted substance use more frequently than internal medicine physicians for alcohol and illicit drugs (P < .05 by Pearson's chi-square analysis) and for cigarettes (P = .07). In each specialty, residents charted substance use more often than attending physicians (P < .01). Attending family physicians (P < .05) charted substance use more often in male than in female patients. This was not found among internal medicine physicians.
The results of the study suggest that the stage of medical career, medical specialty, and sex of the patient affect the frequency of charting substance abuse.