Do stigmatizing information or comorbidities affect medical documentation? Implications for continuity of care

Background: Complete medical documentation is essential to ensure continuity and quality of health care. Past research with mental health (MH) clinicians shows that documenting stigmatizing information can present difficulties given the need for patient confidentiality. Although primary care physicians (PCPs) often are the focal point for continuity, little research exists on how they manage stigmatizing information. We examine how PCPs manage medical documentation vis-à-vis stigmatizing information (MH and non-MH) and comorbidities. Methods: Qualitative component of a factorial experiment in which 128 PCPs observed video vignettes of patients with diabetes and one of four comorbidities: schizophrenia with bizarre affect (SBA) or normal affect, depression, or eczema as control. Respondents wrote a chart narrative typical for their practice and participated in a semi-structured interview about what they include and exclude in chart notes. We coded and analyzed interview transcripts for major themes, coded narratives for categories of information included, and compared by comorbidity. Results: Without being asked specifically about stigmatizing information, 44 PCPs (34%) commented on difficulties in documenting it, i.e. whether to include clinically relevant but sensitive information in charts, how to word it, and how to explain to patients the importance of including relevant information. Strategies for managing stigmatizing MH and non-MH information were identified by 30 and 80 PCPs, respectively. While strategies were similar for MH and non-MH information, frequencies differed somewhat by type: exclude stigmatizing information to respect patient confidentiality (MH:27%, non-MH:34%); include but neutralize information to minimize potential stigma (MH:23%, non-MH: 24%); include but restrict access to information by using sticky notes (non-MH only:17%); include it given the potential impact on health care or to aid memory (MH:50%, non-MH:25%). In their chart narratives, PCPs excluded socio-emotional and compliance information more often for patients with SBA compared to other groups. Conclusions: PCPs have difficulty with managing stigmatizing information and employ a range of strategies that are used more or less frequently depending on the type of information. As incomplete documentation of medically relevant information may impact continuity and quality of care, strategies are needed to assist PCPs in consistently documenting appropriate information while protecting patient confidentiality, and providers may benefit from models for effectively explaining to patients the importance of including stigmatizing information. The finding that PCPs exclude information more often for patients with SBA is consistent with prior studies, but additional research is needed to determine why this exclusion occurs, particularly regarding the role of patient affect.