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  1. Completeness of prescription recording in outpatient medical records from a health maintenance organization.

    Article - En anglais

    Since validity of drug data is often characterized by the agreement between questionnaire and medical record data, medical record completeness for drug therapy was evaluated.

    Outpatient medical records of 501 randomly selected Group Health Cooperative Health Maintenance Organization (HMO) participants known to have been dispensed a non-steroidal anti-inflammatory drug (NSAID) were reviewed for completeness.

    Documentation was also evaluated for indication, age, gender, location of visit, and number of visits.

    The NSAID was recorded in 89% of the charts reviewed.

    Charts with a vague/missing diagnosis were more likely to lack documentation [RR (95% CI): 20.0 (13.2-30.3)]. The data suggested that poorer documentation was related to older age [1.5 (0.9-2.5)] but not to gender, indication, location of visit, or number of visits.

    Mots-clés Pascal : Dossier médical, Prescription médicale, Antiinflammatoire non stéroïde, Validité, Ambulatoire, Homme, Source information, Documentation, Epidémiologie, Méthodologie

    Mots-clés Pascal anglais : Medical record, Medical prescription, Non steroidal antiinflammatory agent, Validity, Ambulatory, Human, Information source, Documentation, Epidemiology, Methodology

    Logo du centre Notice produite par :
    Inist-CNRS - Institut de l'Information Scientifique et Technique

    Cote : 94-0218792

    Code Inist : 002B30A01A1. Création : 199406.