title: Completeness of prescription recording in outpatient medical records from a health maintenance organization.
abstract: 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.
authors.affiliation: Department of Epidemiology, School of Public Health, University of North Carolina, Chapel Hill 27599.
authors.forename: S L
authors.initials: SL
authors.lastname: West
authors.forename: B L
authors.initials: BL
authors.lastname: Strom
authors.forename: B
authors.initials: B
authors.lastname: Freundlich
authors.forename: E
authors.initials: E
authors.lastname: Normand
authors.forename: G
authors.initials: G
authors.lastname: Koch
authors.forename: D A
authors.initials: DA
authors.lastname: Savitz
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000554:Ambulatory Care Facilities; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000627:therapeutic use; D016208:Databases, Factual; D004282:Documentation / Q000592:standards*; D004358:Drug Therapy / Q000706:statistics & numerical data*; D004632:Emergency Medical Services; D005260:Female; D006279:Health Maintenance Organizations; D006801:Humans; D008297:Male; D008499:Medical Records / Q000592:standards*; D008875:Middle Aged; D010594:Pharmacies / Q000706:statistics & numerical data; D012189:Retrospective Studies
chemical_list: D000894:Anti-Inflammatory Agents, Non-Steroidal