Written communication about the use of medications in medical records
during patients' hospitalization in Brazil
Abstract
Background. Effective communication regarding the use of medications in
a hospital environment is a process that contributes to the promotion of
patient safety. Despite its importance, especially for medication
reconciliation, written communication about the use of medications in
medical records remains insufficiently investigated. Aim. To describe
the documentation in medical records regarding the medication use
process by pharmacists, physicians and nurses on admission, during the
hospital stay, and on hospital discharge.Method. A retrospective
cross-sectional chart review study was carried out in medical records of
patients admitted to a teaching hospital in Northeast Brazil. The study
considered all patients admitted between December 2016 and February
2017, aged 18 or older and hospitalized for at least 48 hours. The
clinical notes made by pharmacists, physicians and nurses were examined
at three transition points of care. Data were collected using a
developed questionnaire and aimed at gathering the use of medications
prior to hospital admission, changes in the prescribed medications in
hospital stay and discharge, as well as prescription non-conformities.
Non-conformities were considered as any irregularities reported by the
healthcare team involving the medication use process. Communication
failures between the three healthcare professionals were also analyzed
and classified. Results. This study included 202 patients with a mean
age of 51.48 (SD 6.42, range: 19-97) years. There was no record of a
patient or relative interview on allergies and adverse drug reactions in
54 (26.8%) physician notes, 44 (21.9%) nursing notes, and 8 (22.9%)
of pharmacist notes. Moreover, 1,588 changes in prescriptions were
identified during data collection, but only 390 (24.5%) of these
changes were justified. Conclusion. Medication-related information in
medical records was incomplete and inconsistent in the clinical notes of
the three studied professions, especially in the pharmacists’
documentation. Future studies should focus on investigating the
consequences of interprofessional communication in patient care.