RECORDING OF DRUG PRESCRIPTIONS IN MEDICA L RECORDS

OBJECTIVE To describe the evaluation of a program to improve the recor ding of drug prescribing in medical record. DESIGN Experimental study with before and after measurements, without a control group, of the me dical files of all patients who consulted during 2 different weeks, 9 months apart. SETTING Family Medicine Unit of Centre hospitalier de l' Universite Laval. PARTICIPANTS Teachers and residents in the Family Me dicine Unit. MAIN OUTCOME MEASURE Proportion of prescriptions for drug s having a systemic effect (n=206 for week before, n=257 for week afte r) for which the following information was recorded: concentration, do sage, quantity prescribed or length of treatment, number of renewals. RESULTS After the program, recording frequency increased from 86% to 9 7% for concentration, 80% to 95% for dosage, 52% to 79% for the quanti ty prescribed, and 20% to 71% for number of renewals. Both groups of d octors showed a notable improvement, except for the recording of quant ity prescribed by residents, which remained stable. CONCLUSION We obse rved an improvement in the recording of drug prescriptions in medical files. The program had a greater effect on teachers who had been expos ed to activities that are known to be effective in improving recording .