The accuracy of the medical record as an index of outpatient drug therapy
R. A. Monson and C. A. Bond
The records of 355 patients in outpatient clinics at Madison Veterans
Administration Hospital were reviewed and compared with pharmacy files of
the same patients. The records were evaluated for completeness and
accuracy, with regard to the names, dosage, and directions for drugs
ordered by the clinic physician. Twenty-one percent of the charts omitted
the name of one or more drugs prescribed by the physicians, and 62% of the
charts contained inaccuracies regarding dosage or directions. Documentation
of potentially toxic drugs was not significantly different from that of
less toxic drugs (p greater than .05).
