Insights into creation and use of prescribing documentation in the hospital medical record

Extraction of prescribing data from medical records is a common, albeit flawed, research method. Yet little is known about the processes that result in those data. This study explores the creation and use of prescribing documentation in the medical record, from the perspective of the hospital doctors who both create and use it.

Thirty-six hospital doctors were purposely selected for qualitative interviews, giving a maximum variability sample of grades of doctors across the range of major medical specialty areas and medical teams at a large teaching hospital in England.

The findings suggest a number of reasons why hospital doctors fail to record prescribing decisions in the medical record. There was no set standard, record keeping was not formally taught and the hurried environment of the ward gave little time for documentation. The doctors also acknowledged that there was no need for completeness, as colleagues would be able to 'fill in the gaps' via an inferential process. Assumptions were made and although this was not seen as ideal, it was recognized as necessary if work was to be done efficiently.

These results reinforce the suggestion that, despite the large number of potential users, the medical record is created for those with the right privileged knowledge. This has profound implications for those without that insider knowledge who are using medical records for research purposes.

This work was funded by a North West Regional National Health Service Postdoctoral Fellowship.