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Related Experiment Videos

Medication review and documentation in physician office practice.

M E Jaski1, J G Schwartzberg, R A Guttman

  • 1American Medical Association, Chicago, Ill., USA.

Effective Clinical Practice : ECP
|May 2, 2000
PubMed
Summary

Physicians commonly document prescription drugs but rarely document non-prescription items like supplements and herbal remedies. Reviewing these non-prescription substances before prescribing new medications is also uncommon in primary care.

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Area of Science:

  • Pharmacovigilance
  • Primary Care Medicine
  • Health Informatics

Background:

  • Adverse drug reactions and drug-drug interactions pose significant health risks.
  • Effective medication management, including documentation and review, can prevent medication-induced morbidity.

Purpose of the Study:

  • To examine the practice patterns of primary care physicians regarding the documentation and review of various medication types.
  • To assess the extent to which physicians consider prescription drugs, over-the-counter drugs (OTCs), nutritional supplements, and alternative treatments in their prescribing decisions.

Main Methods:

  • A survey was conducted among a stratified random sample of 1802 internists and family practitioners.
  • Physician self-reported data on documentation and review practices were collected and analyzed.

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Main Results:

  • Nearly all physicians document prescription drugs (99.8%) and review them before new prescriptions (99.8%).
  • Documentation rates for OTCs (68%), nutritional supplements (63%), and herbal/alternative treatments (47%) were considerably lower.
  • Review of OTCs (86%) was common, but review of supplements and herbal/alternative treatments was infrequent (less than 50%).

Conclusions:

  • Self-reported data and a low response rate suggest actual documentation and review rates may be lower.
  • The study highlights that review and documentation of nonprescription substances are not routine in primary care practice.
  • There is a need to improve the comprehensive assessment of all patient-taken substances to enhance medication safety.