Buurma Henk, De Smet Peter A G M, Kruijtbosch Martine, Egberts Antoine C G
SIR Institute for Pharmacy Practice Research, Leiden, Netherlands.
Ann Pharmacother. 2005 Oct;39(10):1640-6. doi: 10.1345/aph.1G071. Epub 2005 Sep 13.
Documentation of diseases and intolerabilities in electronic patient records (EPRs) in pharmacies is needed to produce an alert in case a contraindicated medicine is prescribed. Limited research is available concerning EPRs in pharmacies.
To study the prevalence and quality of documentation of diseases and intolerabilities in EPRs in a sample of Dutch community pharmacies.
Each participating pharmacy (N = 79) collected data on one day in May 2003 for each patient enrolled into the study (N = 687) concerning demographics, drug use, and documentation of diseases and intolerabilities.
In 57.4% of the EPRs, at least one disease and, in 7.9%, at least one intolerability was documented. Higher age, number of drugs used, and chronic disease score were associated with any documentation of a disease/intolerability in the EPR. The highest sensitivity scores (completeness) were found for diabetes (84.7%), asthma/chronic obstructive pulmonary disease (strict definition: 75.9%), and hypothyroidism (75.0%). Rather low values were found for prostatic hyperplasia (55.6%) and heart failure (29.4%). The positive predictive value (reliability) was high for hypothyroidism (100%) and diabetes (87.1%).
In a selection of Dutch pharmacies, at least one documented disease and/or intolerability was found in the EPR of almost 60% of the patients. Certain diseases were documented to a relatively high degree; others had poorer levels of documentation. For optimal surveillance of drug-disease interactions in pharmacies, the frequency and quality of disease and intolerability documentation need further improvement.
为了在开具禁忌药物时发出警报，需要在药房的电子病历（EPR）中记录疾病和不耐受情况。关于药房电子病历的研究有限。
研究荷兰社区药房样本中电子病历中疾病和不耐受情况记录的患病率和质量。
每家参与的药房（N = 79）于2003年5月的一天收集了纳入研究的每位患者（N = 687）的人口统计学、药物使用以及疾病和不耐受情况记录的数据。
在57.4%的电子病历中记录了至少一种疾病，7.9%的电子病历中记录了至少一种不耐受情况。年龄较大、使用药物数量较多以及慢性病评分较高与电子病历中记录任何疾病/不耐受情况相关。糖尿病（84.7%）、哮喘/慢性阻塞性肺疾病（严格定义：75.9%）和甲状腺功能减退（75.0%）的敏感性评分（完整性）最高。前列腺增生（55.6%）和心力衰竭（29.4%）的评分较低。甲状腺功能减退（100%）和糖尿病（87.1%）的阳性预测值（可靠性）较高。
在荷兰的部分药房中，近60%患者的电子病历中发现了至少一种记录的疾病和/或不耐受情况。某些疾病的记录程度相对较高；其他疾病的记录水平较差。为了在药房中对药物 - 疾病相互作用进行最佳监测，疾病和不耐受情况记录的频率和质量需要进一步提高。
