DISCUSSION
To the best of our knowledge, this is the first study to describe written communication about medication use during admission, hospital stay and discharge in Brazil. Our findings show some gaps in documentation that may have compromised the understanding of medication use processes within the hospital environment.
The physicians’ and nurses’ clinical notes were present in almost all medical records analyzed, while the pharmacists’ documentation was less prevalent. Other studies have shown that pharmacists are less likely to document their interventions.29–33 Deficiencies in training, lack of involvement in the healthcare team, as well as clarity of work processes are factors that may influence this finding. Furthermore, Rixon et al. (2014) states that the healthcare team prefers spoken communication over pharmacists’ written communication when searching for immediate medication information.31 In light of this view, it becomes unclear what are the pharmacists’ roles in a multiprofessional patient care environment, since the gaps of documentation do not allow a proper analysis of their interventions. This omission may impair patient care, considering that the integration of pharmacists into core healthcare teams seemed to facilitate better health outcomes, better team decision making regarding medication use, improved continuity of care and patient safety.2,29,40–43,31,32,34–39
Most nurses’ and pharmacists’ notes did not present information on the medication use at admission and hospital discharge, especially the absence of treatment duration. Omission of relevant information on the use of medications may increase days of hospitalization, lead to treatment interruptions and compromise patient safety.44–48 Studies show that omissions occur frequently when health professionals do not question about medication use or when they fail to record the patient’s answer on this matter.48,49,58–61,50–57 Moreover, it is important that health professionals have clarity of their roles and know what information regarding their expertise must be reported in medical records. This clarity enables continuity of care, considering that, in the medication use process, one professional could depend on others’ evaluation. If the healthcare team wants to work collaboratively, complete documentation is essential to enable a more reliable decision-making process regarding patient care.
A notorious number of changes in medication use before and during hospitalization was observed, as well as other studies in literature.3,62–65 However, only a few changes had written justifications. The absence of such information compromises the intentionality analysis of the discrepancies, which impairs medication reconciliation and patient safety. The New South Wales Therapeutic Advisory Group has used documented justifications as a quality indicator for medication use in Australian hospitals, which highlights their importance in driving improvements within the contemporary practice.66
Most medical records presented some type of deficiency in written communication among the professionals evaluated. Vermeir et al. (2015) emphasize that, although spoken communication among healthcare professionals is essential, in clinical practice, written communication remains the most common means of interaction among them.67 Manias et al. (2016) associated communication fails with institution challenges and interprofessional relationships.2 Future studies should be directed to the analysis of the dimensions of communication and how these might interact to promote an efficient transfer of information regarding medications use in hospital settings.
Given the challenges related to documentation, electronic medical records and information software packages have been shown as strategic tools to assist written communication. Their use has been reported to improve interprofessional communication, decrease medication errors and length of intensive care unit stay.68–73 In Brazil, most medical records are paper based as it was in the studied hospital.74,75 The use of paper charts is associated with problems such as prescription illegibility and incompleteness of patient information.76 Some studies indicate that the quality of documentation does not necessarily depend on the adoption of electronic medical records, as it depends on the quality of the process, and, thus, healthcare professional training is required to make good documentation, with the electronic medical records as tools in this process.77–81 Although electronic medical records are recognized as an important strategy for time optimization, their adoption should aim at the integration and qualification of documentation processes, maximizing interaction with the most accurate source of the information - the patient.82,83
The present study has strengths and limitations. We conducted an analysis of documentation of the three professional groups (nurses, physicians, pharmacists) who were directly involved in medication use processes. In addition, the investigation of the completeness of medication-related information in transition points of care is another important factor that deserves to be emphasized.
This study also has some limitations since we did not investigate the clinical relevance of the completeness of information in hospitalization, which could be useful to assess the risks of absent information for patient safety. Another limitation was the lack of proportional analysis of the number of healthcare professionals in the study setting, which could enrich the interpretation of findings.