Does a physician's specialty influence the recording of medication history in patients' case notes?

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT • Physicians undertake the documentation of medication history during clerking; where all the necessary information that guides the diagnostic and patient management tasks are obtained. • Medication histories documented by physicians are often incomplete and generally sketchy; however, the impact of a physician's specialty on the frequency and depth of medication history they document has not been studied. WHAT THIS STUDY ADDS • The depth and frequency of medication history documented by physicians is significantly influenced by their specialties. • Physicians appear more interested in documenting more frequently and in greater depth medication history information that appears to aid diagnostic tasks in their specific specialty. AIMS To determine the impact of a physician's specialty on the frequency and depth of medication history documented in patient medical records. METHODS A cross‐sectional assessment of the frequency and depth of medication history information documented by 123 physicians for 900 randomly selected patients stratified across Cardiology, Chest, Dermatology, Endocrine, Gastroenterology, Haematology, Neurology, Psychiatry and Renal specialties was carried out at a 900‐bed teaching hospital located in Ibadan, Nigeria. RESULTS Four hundred and forty‐three (49.2%) of the cohort were males and 457 (50.8%) were females; with mean ages 43.2 ± 18.6 and 43.1 ± 17.9 years respectively. Physicians' specialties significantly influenced the depth of documentation of the medication history information across the nine specialties ( P  < 0.0001). Post hoc pair‐wise comparisons with Tukey's HSD test showed that the mean scores for adverse drug reactions and adherence to medicines was highest in the Cardiology specialty; while the Chest specialty had the highest mean scores for allergy to drugs, food, chemicals and cigarette smoking. Mean scores for the use of alcohol; illicit drugs; dietary restrictions was highest for Gastroenterology, Psychiatry and Endocrine specialties respectively. Physicians' specialties also significantly influenced the frequency of documentation of the medication history across the nine specialties ( P  < 0.0001). CONCLUSIONS Physicians appear to document more frequently and in greater depth medication history information that may aid the diagnostic tasks in their specific specialty. Researchers and other users of medication history data documented in patients' medical records by physicians may want to take special cognizance of this phenomenon.