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%)