ABSTRACT
To determine the extent to which health screening and preventive measures are actually documented in family practice, a random sample of 216 charts of established patients over 65 in seven practices was audited. Overall, a high rate of documentation (greater than 95%) was observed for blood pressure measurement. Intermediate rates of documentation (35% to 75%) were observed for oral cavity examination, smoking history, and skin examination. Low rates (less than 30%) were present for tetanus immunization, influenza immunization, stool occult blood testing, visual screening, hearing screening, mental status testing, social support description, and discussion of care preferences (living will). Several diagnoses for which screening was infrequently documented were recorded at rates approaching expected community prevalence figures, a finding that suggests widespread performance of informal or undocumented health screening in these practices. Recommended measures to increase the performance and documentation of preventive care include changes in the medical record, alterations in reimbursement, and delegation to nonphysician office staff.
