Physician-patient agreement about depression: notation in medical records

Abstract

Medical patients were prescreened for depression; their physicians were given the results of the screening to see if such intervention altered the frequency of the physicians' appropriate notations about depression in the medical record. As part of this study, physicians' and patients' global ratings of patient depression were examined in relation to Zung Self Rating Depression Scales (SDS) Scores and medical record notation. On their initial encounter in a University General Internal Medicine Clinic, physicians and patients were in close agreement about the extent to which patients felt sad or blue, and these global ratings correlated significantly with patients' self-reports on the SDS. In general, physicians tended to rate patients as more depressed than patients rated themselves. However, although medical record notations about depression were highly correlated with patient and physician global ratings of mood and with SDS scores, notations about depression appeared in only about 70% of charts where the physician assessed the patient's mood as being significantly depressed.