The frequency of drug history documentation in an institutionalized tertiary care setting in Nigeria.

PURPOSE The study set out to investigate the frequency of institutionalized patients' drug history documentation in a tertiary care setting in Nigeria and identify opportunities for intervention to improve documentation. METHOD A cross-sectional retrospective study was carried on June 1st to August 31st 2002 at a 900-bed tertiary care facility located in South Western Nigeria. Stratified random samples of 450 case notes of institutionalized patients who were admitted, discharged or who died at the study site was evaluated for comprehensiveness of drug history documentation with the aid of two pre-piloted data collection forms. RESULT Drug history documentation was done mainly by attending physicians in all 450 case notes studied (100%). Past use of prescription, over-the-counter and herbal drugs were documented in 33.3%, 12.9% and 6.9% of patients respectively. The dose, frequency and duration of use were documented in 6.4% and 8.4% while past side effects experienced were documented in only 1.6%. Allergy to drug(s), food and chemical(s) were documented in 1.4%, 1.8% and 0.8% respectively. Documentation of use of alcohol, cigarette and illicit drugs were done in 36.6%, 23.2% and 4.2% of patients. Patient adherence with drugs used in the past and source(s) of purchase of these drugs were documented in only 10.2% and 6.6% of patients respectively. CONCLUSION The documentation of institutionalized patients' drug history in Nigeria is currently not as detailed as it should be. A planned intervention is on going to identify factors responsible for the observed inadequacy and assess the impact of pharmacists' involvement on the quality of drug history documentation.