Altered medication orders in medical records.
A 1-month study was conducted at a teaching hospital to determine how often medication orders in a medical record are improperly altered after orders have been written. This was determined by comparing the pharmacy copy of the physician order, which is removed from the medical record as the orders are written, with the medical record after the patient has been discharged. Five percent of the discharged patients whose records were examined had a record which had been improperly changed. This was ascertained by examining 1,125 individual medication orders, of which 4 were found to be altered. The altered records are shown. A policy statement is presented on how to properly correct an entry in a medical record. Inservice training and adequate orientation must be provided for all those who make entries in the medical record.
D004282:Documentation / Q000592:standards*; D011307:Drug Prescriptions; D007087:Illinois; D008499:Medical Records / Q000592:standards*; D008505:Medical Staff, Hospital / Q000592:standards*; D011050:Policy Making