Skip to main content

Table 6 Explanations for incorrect or no documentation in the medical record of the primary care provider

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

No documentation
Incorrect/no notation in prescription overview of primary care provider
Incorrect/no notation in free text fields
126 (100%)
Possible explanation 27 (21.4%)
 Change was temporarily made (e.g. antibiotics) 10
 Change made within two weeks before end 2013 (data not available for 2014) 4
 Acetylsalicylic acid prescribed instead of carbasalate calcium 3
 Patient went to a different care provider shortly after discharge 3
 Change was reversed by patient 3
 Change regarded the number of days a fentanyl patch could be worn 3
 Dosage was changed but was already prescribed in ‘new’ dosage (so primary care provider already had new dosage in medical record) 1
No explanation 99 (78.6%)