Medication review and documentation in physician office practice.

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.

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.