Évaluation de la qualité des dossiers pharmaceutiques utilisés pour les patients hospitalisés dans un hôpital général

Since October 2004, a pharmaceutical file has been created for each patient admitted to one of seven wards packaging inpatients medications orders in unit doses. The aim of this study was to evaluate the filling and the quality of information contained in these records. On a given day, all pharmaceutical records from a unit were evaluated by two pharmacists during an analysis of prescriptions. The following data were sought: patient characteristics, medication history, therapeutic monitoring. The explanations and consequences of lack of information were discussed with each ward pharmacist. Among 107 analyzed pharmaceutical records, patient characteristics were complete for only 7 %, medication history for 15 % and therapeutic follow-up for 31 % of records. The main explanations of information lack in pharmaceutical files were the absence of information search by the referent pharmacist (31 %) or the lack of data in the patient file (25 %). For 39 % of records where information were lacking, the pharmaceutical interventions were delayed. The quality of records can be improved, mainly in the collection of patient data and drug history. Pending computerisation of patient files that could enable more exchange of information, the pharmaceutical team has modified their paper record model.