尼日利亚一家三级医疗机构中药物史记录的频率。

The frequency of drug history documentation in an institutionalized tertiary care setting in Nigeria.

作者信息

Yusuff Kazeem, Awotunde Mikhail

机构信息

Department of Clinical Pharmacy & Pharmacy Administration, Faculty of Pharmacy, University of Ibadan, Ibadan, Nigeria.

出版信息

J Pharm Pharm Sci. 2005 Jun 29;8(2):141-6.

PMID:16124925

Abstract

PURPOSE

The study set out to investigate the frequency of institutionalized patients' drug history documentation in a tertiary care setting in Nigeria and identify opportunities for intervention to improve documentation.

METHOD

A cross-sectional retrospective study was carried on June 1st to August 31st 2002 at a 900-bed tertiary care facility located in South Western Nigeria. Stratified random samples of 450 case notes of institutionalized patients who were admitted, discharged or who died at the study site was evaluated for comprehensiveness of drug history documentation with the aid of two pre-piloted data collection forms.

RESULT

Drug history documentation was done mainly by attending physicians in all 450 case notes studied (100%). Past use of prescription, over-the-counter and herbal drugs were documented in 33.3%, 12.9% and 6.9% of patients respectively. The dose, frequency and duration of use were documented in 6.4% and 8.4% while past side effects experienced were documented in only 1.6%. Allergy to drug(s), food and chemical(s) were documented in 1.4%, 1.8% and 0.8% respectively. Documentation of use of alcohol, cigarette and illicit drugs were done in 36.6%, 23.2% and 4.2% of patients. Patient adherence with drugs used in the past and source(s) of purchase of these drugs were documented in only 10.2% and 6.6% of patients respectively.

CONCLUSION

The documentation of institutionalized patients' drug history in Nigeria is currently not as detailed as it should be. A planned intervention is on going to identify factors responsible for the observed inadequacy and assess the impact of pharmacists' involvement on the quality of drug history documentation.

摘要

目的

本研究旨在调查尼日利亚一家三级医疗机构中住院患者用药史记录的频率，并确定改善记录的干预机会。

方法

2002年6月1日至8月31日，在尼日利亚西南部一家拥有900张床位的三级医疗机构进行了一项横断面回顾性研究。借助两份预先试点的数据收集表，对在研究地点入院、出院或死亡的450例住院患者病历进行分层随机抽样，评估用药史记录的完整性。

结果

在所研究的450份病历中，用药史记录主要由主治医生完成（100%）。分别有33.3%、12.9%和6.9%的患者记录了过去使用的处方药、非处方药和草药。用药剂量、频率和持续时间的记录分别为6.4%和8.4%，而过去经历的副作用记录仅为1.6%。对药物、食物和化学品过敏的记录分别为1.4%、1.8%和0.8%。分别有36.6%、23.2%和4.2%的患者记录了酒精、香烟和非法药物的使用情况。过去患者对所用药物的依从性以及这些药物的购买来源记录分别仅为10.2%和6.6%。