June 17, 2024
Combating Unnecessary Antibiotic Prescriptions

The Importance of Accurate Medical Records in Combating Unnecessary Antibiotic Prescriptions: Two Studies Reveal Gaps in Documentation

Two recent studies led by researchers from the University of Michigan highlight the significance of comprehensive medical record-keeping in addressing the issue of inappropriate antibiotic prescriptions. The studies, published in the Journal of General Internal Medicine and Antimicrobial Stewardship and Healthcare Epidemiology, respectively, reveal concerning gaps in documentation, particularly in emergency departments and among patients with Medicaid coverage or no insurance.

In the first study focusing on outpatient prescribing, approximately 10% of children and 35% of adults received an Antibiotics prescription during a clinic visit without a documented reason in their records. This issue is more prevalent among adults treated in emergency departments and those with Medicaid coverage or no insurance. However, it also affects children.

The second study examines trends in emergency department prescribing and found that around 20% of antibiotic prescriptions lacked a documented indication. This issue is particularly concerning as overuse and misuse of antibiotics can lead to the evolution of antibiotic-resistant bacteria, making these drugs less effective for everyone. Moreover, inappropriately prescribed antibiotics may cause harm to patients without providing any therapeutic benefit.

Joseph Ladines-Lim, M.D., Ph.D., the first author of both studies and a combined internal medicine/pediatrics resident at Michigan Medicine, emphasized the importance of recording why antibiotics are prescribed. “When clinicians fail to document the reason for prescribing antibiotics, it becomes challenging to estimate the number of inappropriate prescriptions and focus on reducing them,” he stated.

Previous estimates of inappropriate prescribing do not distinguish between prescriptions that lack proper coding and those prescribed for conditions that antibiotics cannot treat. Ladines-Lim and his colleague, Kao-Ping Chua, M.D., Ph.D., a pediatrician and healthcare researcher at the University of Michigan, believe that their studies provide valuable context to these estimates.

By shedding light on the importance of accurate medical records, these studies underscore the need for healthcare providers to document the reasons for antibiotic prescriptions to effectively combat unnecessary use and promote better patient care.

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1. Source: Coherent Market Insights, Public Source, Desk Research
2. We have leveraged AI tools to mine information and compile it.