[Recording of drug prescriptions in medical records. How to improve the quality?].

OBJECTIVE

To describe the evaluation of a program to improve the recording of drug prescribing in medical records. DESIGN: Experimental study with before and after measurements, without a control group, of the medical files of all patients who consulted during 2 different weeks, 9 months apart. SETTING: Family Medicine Unit of Centre hospitalier de l'Université Laval. PARTICIPANTS: Teachers and residents in the Family Medicine Unit. MAIN OUTCOME MEASURE: Proportion of prescriptions for drugs having a systemic effect (n = 206 for week before, n = 257 for week after) for which the following information was recorded: concentration, dosage, quantity prescribed or length of treatment, number of renewals. RESULTS: After the program, recording frequency increased from 86% to 97% for concentration, 80% to 95% for dosage, 52% to 79% for the quantity prescribed, and 20% to 71% for number of renewals. Both groups of doctors showed a notable improvement, except for the recording of quantity prescribed by residents, which remained stable. CONCLUSION: We observed an improvement in the recording of drug prescriptions in medical files. The program had a greater effect on teachers who had been exposed to activities that are known to be effective in improving recording.