Accuracy of Medical Records in Documenting Drug Therapy in Routine Surgical Procedures

Abstract

The accuracy of medical records with regard to routine antibiotic prophylaxis was evaluated at a Brazilian hospital. Data were obtained from 99 patients undergoing surgical procedures using two methods: (1) from a specific form filled out by the anesthetist immediately after surgery and (2) from the medical record after approximately 1 month. Data collected in the operating suite were used as our “gold standard” of what actually happened. The likelihood of antibiotic prophylaxis having been used according to the guideline if the medication administration record indicated that it had been was 83%. In cases in which the record reviewer observed that the antibiotic prophylaxis had not been used according to the guideline, the likelihood of patients having, in fact, received the drug correctly was 11%. In conclusion, the medical records were generally accurate.