Detection and documentation of actual and potential medication adherence problems in patients receiving combination...

This article identifies problems in the documentation of antiretroviral medication adherence in medical records of clients seen in community-based treatment centers. Medical record data abstraction was conducted in community-based clinics providing HIV treatment services in a major HIV epicenter. Medical records of a purposive sample of 146 clients in four clinics were reviewed. Results revealed that adherence issues, in both frequency and type, were inadequately documented. Furthermore, when documented, reasons for patient adherence problems were not given. Documentation of follow-up of adherence issues was also absent in the medical records of study participants. There may be several unique and overlapping reasons for problems in documenting adherence issues: (a) provider experience and expertise in assessing adherence problems, (b) lack of sensitivity and specificity in clinician's assessments of adherence, (c) absence of adequate clinic protocol, and (d) available time to both assess adherence and complete thorough progress notes. This article provides data for the formulation of a summary adherence measure to enhance providers' abilities to detect and monitor actual and potential adherence problems.