Medication review and documentation in physician office practice

Adverse drug reactions and drug-drug interactions are common. Medication-induced morbidity might be prevented through the documentation of medicines in the medical record and review of the medical record before new medications are prescribed.

Documentation and review by primary care physicians of patient use of prescription drugs, over-the-counter drugs (OTCs), nutritional supplements, and herbal and other alternative treatments.

A stratified random sample of 1802 internists and family practitioners from the American Medical Association Physician Masterfile was surveyed; 655 physicians responded (response rate, 36%).

99.8% of physicians reported documenting prescription drugs in the medical record. Fewer reported documenting OTCs (68%) or nutritional supplements (63%); only 47% documented herbal and other alternative treatments. Almost all respondents reported reviewing prescription medications before prescribing a new therapy (99.8%), but only 86% reported reviewing OTCs at the same time. Fewer than half of physicians reported reviewing nutritional supplements or herbal and other alternative treatments before prescribing a new therapy.

This study draws on self-reported data, and the response rate was low. Thus, the results probably overestimate actual rates of documentation and review. Review and documentation of nonprescription substances are uncommon in primary care practice.