The Accuracy of the Medical Record as an Index of Outpatient Drug Therapy

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).