Underdocumentation of benzodiazepine prescriptions in a general medicine clinic

Abstract

During a three-month period the authors reviewed the charts of patients prescribed benzodiazepine and non-benzodiazepine medications by 73 housestaff practicing in an ambulatory medical clinic. Compared with non-benzodiazepine prescriptions, benzodiazepine name (p less than 0.001), instructions (p less than 0.001), and targeted problems (p less than 0.0001) were significantly underrecorded. In 11% of the records reviewed there was no indication that a mood disorder had been identified or a benzodiazepine prescribed (p less than 0.0001). Problems targeted for benzodiazepine management were found less frequently in the records of elderly patients than in those of patients less than 65 years of age (p less than 0.05). The authors conclude that many houseofficers significantly underdocument the prescriptions they write for benzodiazepine medications and that this may be a marker of their regard for managing mood disorders with benzodiazepines.