What probable factors underlie inadequacy of medication history information recorded in patients' case notes by physicians in a Nigerian teaching hospital?

Abstract

Abstract Objective To identify probable factors underlying inadequacy of medication history information recorded in patients' case notes by physicians in an ambulatory tertiary care setting in Nigeria. Method A cross-sectional survey was conducted, with a pre-tested 25-item questionnaire, of 93 physicians at the nine medical units in the Department of Medicine at University College Hospital, Ibadan, Nigeria. Key findings The overall response rate was 79.6% (74/93), and the usable rate was 75% (70/93). A majority of physicians opined that a detailed medication history is an essential component of optimal and patient-specific care; and they were able to identify correctly the key components of a detailed medication history. However, about 60% of physicians opined that the adequacy of medication history documented by them is affected by heavy workload due to the large number of patients to which they attend. The majority (75%) of physicians also considered detailed documentation of patient medical history to be more important than medication history. Conclusions Physicians' heavy workload, due to the large number of patients, and their belief that medical history is more important than medication history, appear to be the probable factors underlining the inadequacy of physician-acquired medication history in a developing sub-Saharan tertiary care setting.