Paper based vs. electronic records for clinical audit: Evidence of documentation of medication safety monitoring in youth prescribed antipsychotics

Abstract

• Good documentation practice is the foundation for promoting medication safety in young population. • Study identified poor documentation practice through paper and electronic means of medical records. • Newly introduced electronic medical records did not improve the rates of metabolic monitoring nor the quality of documented monitoring. • Youth are at significant risk for antipsychotic induced metabolic syndrome the repercussion of which may impact years of productivity. • Potentially electronic health records could provide health workers with real-time information access, and develop accurate, relevant and structured information thereby adhering to clinical evidence. Since the development of digital records, claims have been made that they improve audits. Clinical audits play important role in evaluation of evidence-practice gaps. Antipsychotic medications are one of the commonly prescribed group of drugs in severe adverse mental conditions. Youth and young people are highly prone to develop drug induced metabolic syndrome. Present study evaluated the extent of data documentation on evidence for metabolic monitoring of antipsychotics and compared paper based to electronic records with good documentation standards. First phase of this study involved a retrospective clinical audit of paper-based documentation on the extent of documentation of weight (primary outcome); lipid and blood glucose (secondary outcomes) of youth prescribed atypical antipsychotics. This was undertaken in three public mental health clinics and a public/private developmental service in Australia based on paper-based documentation. The second phase included auditing electronic data capture from one community clinic. Evidence of documentation was compared with practice standards and published clinical audits (adherence rate benchmark: 40–60%). A total of 310 cases were assessed of which 51 and 37 cases met the eligibility criteria for paper-based and electronic based audit respectively as a component of clinical audit. Evidence of paper documentation of weight was 43% among participants and was comparable with other published clinical audits (p = 0.07) with poor monitoring rates for other blood tests. Findings revealed poor rate of documentation at 35.1% (13 cases), 5.4% (2 cases) and 8.1% (3 cases) for weight, lipid assessments and glucose monitoring, respectively based on electronic records. Present study demonstrate lack of good documentation practices on metabolic monitoring of youth prescribed antipsychotics. It appears transitioning from paper to electronic records did not impact the rate of increase in documentation of metabolic monitoring. This study recommends inclusion of e-monitoring icon with built in metabolic monitoring chart as a component of youth prescribed antipsychotic case records. Good documentation practice is a first step in determination of causality of antipsychotics induced metabolic syndrome. Appropriate strategies to a user-friendly electronic reminder system will be crucial to address on the mechanistic of documentation.research; tables/charts. Journal Subset: Biomedical; USA. NLM UID: 8110100. <br />