INTRODUCTION
Effective communication
regarding the use of medications in hospital environments is a dynamic
and complex process that contributes to the promotion of patient
safety.1 Regarding communication between the
healthcare team, Manias et al. (2016) highlights that when patient
information is complete, the continuity of care can be ensured,
especially at transition points of care.2
In this context, the medical record should be the main document that
mirrors the patient’s history, from hospital admission to discharge,
allowing the continuity of care.3,4 Mathioudakis et
al. (2016) point out that accurate medical record keeping is integral to
good professional practice and the delivery of quality
healthcare.5 According to these authors, medical
records must describe treatment details and future treatment
recommendations besides every medication administered, prescribed or
renewed and any drug allergies.
Recent evidence suggests that when the medical record is not well
documented, the transfer of information among healthcare professionals
may be impaired.6 Communication failure, defined as a
flaw in the content, audience, occasion or purpose of the communication
act, has been widely reported regarding the use of
medications.4,7–10 Furthermore, documentation gaps
can cause medication errors, such as unintended medication
discrepancies. These occur when there is a change in the pharmacotherapy
without clinical justification in the transition points of care, or when
the intentionality of the change is not recorded.11,12Thus, medication reconciliation emerges as the most effective strategy
to solve such issues.13–15
The literature points out challenges related to the implementation and
consolidation of medication reconciliation, with the quality and
reliability of the recording of medication information described as
challenges still to be overcome.8,16–18 Ideally, all
medications that the patient uses before, during and after
hospitalization should be documented in the medical record, as well as
any changes and justifications for them, improving the communication
between the healthcare team.3,19 Complete
documentation ensures that relevant information for healthcare decision
making is available, providing effective evaluation and monitoring of
treatment, decreasing episodes of medication omissions and therapeutic
duplicity.20,21
There are legal issues to ensure good quality documentation
recommendations for the United Kingdom, Australia, most of the United
States, France and other countries.5 In Brazil,
studies evaluating the quality and content of medical records are still
scarce. Lack of research in this area means that it is difficult to
understand how information contained in medical records affects
assessment of adverse events and medication
errors.22–25 Thus, the present study aimed to
describe the documentation in medical records regarding the medication
use process by pharmacists, physicians and nurses on admission, hospital
stay, and hospital discharge.