Differences between patient medication records held by general practitioners and the drugs actually consumed by the patients

Abstract

Objective: The pattern of drugs actually consumed by patients can differ from that shown in the medical records held by the general practitioners. Reasons for such differences, in patients receiving polypharmacy, were analyzed in this study. Materials and methods: Medication records provided by general practitioners (GP) were compared with the pattern of drugs actively taken by their patients. Reasons to explain why drugs taken by patients were missing from their physician's records were analyzed on the basis of information obtained from interviews with GPs. Results: Discrepancies involved 170 drugs in 87 patients and > 90% of the discrepancies could be attributed to four causes. These were: 1. Organizational aspects 2. Lack of documentation 3. A drug prescribed by a specialist without informing the GP, and 4. Patients' use of over the-counter medication (OTCs). Drugs most affected were magnesium and acetylsalicylic acid. Conclusion: Omissions in medication records held by GPs are mostly due to organizational deficiencies in information transfer.