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.