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Abstract:
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.
Insights
Improper alterations to medication orders in medical records occurred in 5% of patients studied. This highlights a need for improved record-keeping accuracy and staff training to ensure patient safety.
Area of Science:
- Medical record accuracy
- Patient safety
- Medication order management
Background:
- Medication orders are critical for patient care.
- Ensuring the integrity of medical records is essential for safe practice.
- Previous data on medication order alteration rates are limited.
Purpose of the Study:
- To determine the frequency of improper alterations to medication orders in a teaching hospital.
- To identify the rate of discrepancies between original physician orders and the final medical record.
- To provide evidence supporting improved medical record documentation policies.
Main Methods:
- A 1-month prospective study was conducted at a teaching hospital.
- Pharmacy copies of physician orders were compared with the final medical record post-discharge.
- 1,125 individual medication orders were examined for alterations.
Main Results:
- Five percent (5%) of discharged patients' records showed improper changes to medication orders.
- Out of 1,125 examined orders, 4 were found to be altered.
- Specific examples of altered records were documented.
Conclusions:
- Improper alteration of medication orders in medical records is a significant issue.
- Enhanced in-service training and orientation are necessary for all personnel involved in record entries.
- Implementing a clear policy for correcting medical record entries is recommended.