Skip to main content

Table 2 Type of documentation of prescription changes, divided by the type of prescription change (start, stop, dose/frequency change and switch)

From: In-hospital prescription changes and documentation in the medical records of the primary care provider: results from a medical record review study

  Correct documentation
Correct notation in prescription overview of PCP
Correct notation in free text fields
Inadequate documentation
Incorrect/no notation in prescription overview of PCP; Correct notation in free text fields
OR
Correct notation in prescription overview of PCP; Incorrect notation in free text fields
No documentation
Incorrect/no notation in prescription overview of PCP
Incorrect/no notation in free text fields
Total number of changes:
n = 408 (100%)
86 (21.1%) 196 (48.0%) 126 (30.9%)
Type of change within the types of documentation
 Starta
n = 220 (53.9%)
43/86 (50.0%)e 117/196 (59.7%) 60/126 (47.6%)
 Stopb
n = 77 (18.9%)
21/86 (24.4%) 43/196 (22.0%) 13/126 (10.3%)
 Dose/freq changec
n = 87 (21.3%)
17/86 (19.8%) 24/196 (12.2%) 46/126 (36.5%)
 Switchd
n = 24 (5.9%)
5/86 (5.8%) 12/196 (6.1%) 7/126 (5.6%)
  1. PCP primary care provider
  2. aA new medication was added
  3. bA medication was stopped
  4. cThe dose or frequency of a medication was changed
  5. dThere was a switch from one medication to another in the same medication group
  6. ePercentages shown are the type of change (e.g. “Start”) divided by the total number of changes in this particular type of documentation (e.g. “Correct documentation”)