Completeness of prescription recording in outpatient medical records from a health maintenance organization
Autor: | David A. Savitz, Esther H. Normand, Bruce Freundlich, Brian L. Strom, Gary G. Koch, Suzanne L West |
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Rok vydání: | 1994 |
Předmět: |
Male
medicine.medical_specialty Pediatrics Emergency Medical Services Databases Factual Epidemiology Concordance Alternative medicine Documentation Ambulatory Care Facilities Medical Records Drug Therapy medicine Humans Medical prescription Aged Retrospective Studies Aged 80 and over Pharmacies business.industry Public health Medical record Anti-Inflammatory Agents Non-Steroidal Age Factors Health Maintenance Organizations Middle Aged Family medicine Ambulatory Female business |
Zdroj: | Journal of clinical epidemiology. 47(2) |
ISSN: | 0895-4356 |
Popis: | Since validity of drug data is often characterized by the agreement between questionnaire and medical record data, medical record completeness for drug therapy was evaluated. Outpatient medical records of 501 randomly selected Group Health Cooperative Health Maintenance Organization (HMO) participants known to have been dispensed a non-steroidal anti-inflammatory drug (NSAID) were reviewed for completeness. Documentation was also evaluated for indication, age, gender, location of visit, and number of visits. The NSAID was recorded in 89% of the charts reviewed. Charts with a vague/missing diagnosis were more likely to lack documentation [RR (95% CI): 20.0 (13.2–30.3)]. The data suggested that poorer documentation was related to older age [1.5 (0.9-2.5)] but not to gender, indication, location of visit, or number of visits. Presence of an indication was positively correlated to the completeness of drug documentation. According to this staff/group HMO, there may be a higher concordance between self-reported medication use and medical record data than found in previous literature. |
Databáze: | OpenAIRE |
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