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Open Access Research article

Medication documentation in a primary care network serving North Carolina medicaid patients: results of a cross-sectional chart review

Matthew D Olson1, Gretchen L Tong2*, Beat D Steiner2, Anthony J Viera2, Evan Ashkin2 and Warren P Newton2

Author Affiliations

1 Marshfield Clinic – Lake Hallie Center, Department of Family Practice, , 12961 27th Avenue, Chippewa Falls, WI, 54729, USA

2 Department of Family Medicine, University of North Carolina School of Medicine, CB #7595, Chapel Hill, NC 27599, USA

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BMC Family Practice 2012, 13:83  doi:10.1186/1471-2296-13-83

Published: 13 August 2012

Abstract

Background

Medical records that do not accurately reflect the patient’s current medication list are an open invitation to errors and may compromise patient safety.

Methods

This cross-sectional study compares primary care provider (PCP) medication lists and pharmacy claims for 100 patients seen in 8 primary care practices and examines the association of congruence with demographic, clinical, and practice characteristics. Medication list congruence was measured as agreement of pharmacy claims with the entire PCP chart, including current medication list, visit notes, and correspondence sections.

Results

Congruence between pharmacy claims and the PCP chart was 65%. Congruence was associated with large chronic disease burden, frequent PCP visits, group practice, and patient age ≥45 years.

Conclusion

Agreement of medication lists between the PCP chart and pharmacy records is low. Medication documentation was more accurate among patients who have more chronic conditions, those who have frequent PCP visits, those whose practice has multiple providers, and those at least 45 years of age. Improved congruence among patients with multiple chronic conditions and in group practices may reflect more frequent visits and reviews by providers.

Keywords:
Congruence; Medication documentation; Medical record; Patient safety; Medication discrepancy; Community Care of North Carolina; Community network