Documentation quality in community pharmacy: completeness of electronic patient records after patients' first visits.
BACKGROUND
When patients visit a community pharmacy for the first time, the creation of an electronic patient record (EPR) with relevant and up-to-date data is a prerequisite for adequate medication surveillance and patient counseling.


OBJECTIVE
To investigate the level of completeness of documentation in the EPR after a patient's first visit to a Dutch community pharmacy.


METHODS
In each participating pharmacy, newly enlisted (<3 mo) patients to whom at least one medication had been dispensed were enrolled in this survey. For each patient who could be interviewed, pharmacy master students used a structured questionnaire to gather relevant, mandatory patient data (ie, basic characteristics, current drugs used, diseases, intolerabilities, specific conditions) and nonmandatory patient data (eg, diagnostic and monitoring data, personal experiences and habits, drug use problems) from the patient's EPR and from a structured telephone interview with the patient. Data retrieved from the patient's EPR were compared with data provided by the patient during the telephone interview.


RESULTS
Of 403 selected patients, 154 (38.2%) could be interviewed by telephone. Poor documentation of telephone numbers in the EPR was the main reason for nonresponse (134/249). Interviewers found that 67.7% of prescription drugs, 0% of over-the-counter drugs, 19.6% of diseases, 3.7% of intolerabilities, and none of the specific conditions reported by patients had been documented in the EPR. Nonmandatory data (personal experiences and habits, drug use problems) reported during the patient interview had not been documented in the EPR.


CONCLUSIONS
The EPR after a patient's first visit to the community pharmacy is often incomplete. For new patients, the pharmacist should more proactively and systematically gather patient information, and all relevant information should be recorded, preferably in coded form, in the pharmacy information system to allow more adequate clinical risk management.
Floor-Schreudering
Annemieke
A
SIR Institute for Pharmacy Practice and Policy, Leiden, Netherlands.
De Smet
Peter A G M
PA
Buurma
Henk
H
Egberts
Antoine C G
AC
Bouvy
Marcel L
ML
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002675:Child, Preschool; D003157:Community Pharmacy Services / Q000592:standards*; D003266:Continuity of Patient Care / Q000592:standards; D004282:Documentation / Q000379:methods / Q000592:standards*; D057286:Electronic Health Records / Q000592:standards*; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008875:Middle Aged; D009426:Netherlands; D009819:Office Visits; D055815:Young Adult