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Its under-documentation is also a concern: the initial project and engineering documentation is almost completely lost.
Under-documentation can create problems, but if it appears that you're singling out an employee for extra scrutiny especially if that worker is a member of a protected racial, ethnic or other class the plaintiff's bar will thank you.
However, this may have led to under-documentation of the true rate of clinical events.
These rates of under-documentation are consistent with the peer-reviewed literature [ 25].
This may be due to under-detection, under-recognition or under-documentation of HIV infection during delivery.
Numerous studies have verified the under-recognition and under-documentation of delirium by both physician and nursing staff [ 21- 23].
Moreover, cultural factors within Black communities could foster relative under-documentation of psychiatric comorbidity on the death certificates of their suicides.
Other preliminary studies conducted by authors LG and OW have shown significant proportions of under-documentation of geriatric syndromes and risks in patient medical files (unpublished data).
Under-documentation in medical records is well known and, therefore, some visits deemed as not related to gout based on the medical record gold standard may have been labeled incorrectly.
Under-documentation of delirium in the medical record is supported by our findings, in that there was no chart documentation for 36% (105/292) of delirium cases identified by the CAM-ICU.
Substantial rates of under-documentation by medical students were already shown by Szauter et al. and Worzala et al. for the context of post-encounter notes, possibly due to forgetfulness or inaccurate decisions on what is relevant and what is not [ 19, 20].
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Justyna Jupowicz-Kozak
CEO of Professional Science Editing for Scientists @ prosciediting.com