Schmiemann Guido, Bahr Marcel, Gurjanov Alla, Hummers-Pradier Eva
Department of Health Service Research, Institute of Public Health and Nursing Resaerch, University Bremen, Germany.
Int J Clin Pharmacol Ther. 2012 Aug;50(8):614-7. doi: 10.5414/CP201682.
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.
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.
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.
Omissions in medication records held by GPs are mostly due to organizational deficiencies in information transfer.
患者实际服用的药物模式可能与全科医生保存的病历中显示的模式不同。本研究分析了接受多种药物治疗的患者出现这种差异的原因。
将全科医生（GP）提供的用药记录与其患者实际服用的药物模式进行比较。根据对全科医生访谈获得的信息，分析了患者服用的药物未在医生记录中出现的原因。
87名患者涉及170种药物存在差异，超过90%的差异可归因于四个原因。这些原因是：1. 组织方面；2. 缺乏记录；3. 专科医生开了药但未告知全科医生；4. 患者使用非处方药（OTC）。受影响最大的药物是镁和乙酰水杨酸。
全科医生保存的用药记录中的遗漏主要是由于信息传递中的组织缺陷。
