†Only female patients' chart contained documentation of safety planning.
Only 17.3% (n=14) of the 81 charts in which an AE was found contained documentation of an incident report, while 4.8% (n=54) of charts without an AE did.
Of the 95 charts reviewed, five contained documentation of abuse that was not partner-inflicted (for example, political violence in foreign countries).
General entries pertaining to provision of lifestyle advice were identified by noting records that contained documentation of provision of patient information leaflets (n = 11; 4%) and "lifestyle advice" (n =7; 2%) (see Table 3), such entries were not mutually exclusive.
Additionally, counseling about weight gain is an explicit recommendation in the obesity guidelines [ 12, 13] although we found that only a minority of charts either overall or in obese women contained documentation of a recommendation of weight gain.
When documentation of time spent on counseling was present in EMR notes containing documentation of lifestyle counseling, distinct counseling was associated with a significant increase in the E&M charge level, as expected.
In fact, if the medical record contained documentation of a positive value that was reported on the RVCT as 'unknown' or 'not done,' our estimates would have excluded these discordant values, thereby resulting in a higher estimate of sensitivity.
For medication documentation, we created a dichotomous (yes/no) variable that was scored "yes" if the record contained documentation of current medications either in the encounter text of the complete history and physical examination or in the medication list (i.e., medication field) of the computerized medical record.
21, 22 Patients were considered to have poor performance status if the medical record contained documentation of any of the following: Eastern Cooperative Oncology Group score >2, Karnofsky Performance Status Scale score <60%, or an Adult Comorbidity Evaluation-27 (ACE-27) score of moderate or severe (2 or 3).
