[Medication records reduce medication errors when transferring and discharging hospitalized patients].
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This study refined an existing Allied Health Career Attitude Scale (AHCAS) and measured the attitudes of a nationwide sample of students in medical record administration and medical technology. A survey of seniors enrolled in 35 medical record administration and 37 medical technology programs was conducted with 756 usable student responses. The 39-item questionnaire was used to measure the satisfaction of seniors with their career choice, motivation to participate in professional organizations, and career outlook. On the total scale, scores of medical record administration students were significantly more positive. No significant difference was found between groups on the subscale measuring satisfaction with career choice. Medical record administration seniors were significantly more positive on the subscale measuring motivation to participate in professional organizations and the subscale measuring career outlook. The paper contains various interpretations of these findings with suggestions for the use of the scale by allied health educators.
As a pioneer of patient safety, the Department of Veterans Affairs continues to develop a variety of computerized tools to reduce medication errors.
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Since validity of drug data is often characterized by the agreement between questionnaire and medical record data, medical record completeness for drug therapy was evaluated. Outpatient medical records of 501 randomly selected Group Health Cooperative Health Maintenance Organization (HMO) participants known to have been dispensed a non-steroidal anti-inflammatory drug (NSAID) were reviewed for completeness. Documentation was also evaluated for indication, age, gender, location of visit, and number of visits. The NSAID was recorded in 89% of the charts reviewed. Charts with a vague/missing diagnosis were more likely to lack documentation [RR (95% CI): 20.0 (13.2-30.3)]. The data suggested that poorer documentation was related to older age [1.5 (0.9-2.5)] but not to gender, indication, location of visit, or number of visits. Presence of an indication was positively correlated to the completeness of drug documentation. According to this staff/group HMO, there may be a higher concordance between self-reported medication use and medical record data than found in previous literature.
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