TABLE 1.

Definitions and Prevalence of Medication and Line Documentation Discrepancies

Discrepancy TypeDefinitionPercentage of Notes
Medication omissionProgress note does not record a medication the patient received18.2% (39/214)
Medication commissionProgress note records a medication the patient did not receive18.6% (63/339)
Line omissionProgress note does not record a line the patient has in place13.9% (34/245)
Line commissionProgress note records a line the patient does not have in place30.1% (102/339)