COMPLETENESS OF PRESCRIPTION RECORDING IN OUTPATIENT MEDICAL RECORDS FROM A HEALTH-MAINTENANCE-ORGANIZATION

Since validity of drug data is often characterized by the agreement be tween questionnaire and medical record data, medical record completene ss for drug therapy was evaluated. Outpatient medical records of 501 r andomly selected Group Health Cooperative Health Maintenance Organizat ion (HMO) participants known to have been dispensed a non-steroidal an ti-inflammatory drug (NSAID) were reviewed for completeness. Documenta tion was also evaluated for indication, age, gender, location of visit , and number of visits. The NSAID was recorded in 89% of the charts re viewed. Charts with a vague/missing diagnosis were more likely to lack documentation [RR (95% CI): 20.0 (13.2-30.3)]. The data suggested tha t poorer documentation was related to older age [1.5 (0.9-2.5)] but no t to gender, indication, location of visit, or number of visits. Prese nce of an indication was positively correlated to the completeness of drug documentation. According to this staff/group HMO, there may be a higher concordance between self-reported medication use and medical re cord data than found in previous literature.