Contribution of Different Patient Information Sources to Create the Best Possible Medication History

Abstract

Introduction: Obtaining the best possible medication history is the crucial step in medication reconciliation. Our aim was to evaluate the potential contributions of the main data sources available – patient/caregiver, hospital medical records, and shared electronic health records – to obtain an accurate ‘best possible medication history’.Material and Methods: An observational cross-sectional study was conducted. Adult patients taking at least one medicine were included. Patient interview was performed upon admission and this information was reconciled with hospital medical records and shared electronic health records, assessed retrospectively. Concordance between sources was assessed. In the shared electronic health records, information was collected for four time-periods: the preceding three, six, nine and 12-months. The proportion of omitted data between time-periods was analysed.Results: A total of 148 patients were admitted, with a mean age of 54.6 ± 16.3 years. A total of 1639 medicines were retrieved. Only 29% were collected simultaneously in the three sources of information, 40% were only obtained in shared electronic health records and only 5% were obtained exclusively from patients. The total number of medicines gathered in shared electronic health records considering the different time frames were 778 (three-months), 1397 (six-months), 1748 (nine-months), and 1933 (12-months).Discussion: The use of shared electronic health records provides data that were omitted in the other data sources available and retrieving the information at six months is the most efficient procedure to establish the basis of the best possible medication history.Conclusion: Shared electronic health records should be the preferred source of information to supplement the patient or caregiver interview in order to increase the accuracy of best possible medication history of the patient, particularly if collected within the prior six months.

Reconciliação Terapêutica na Admissão de um Serviço de Medicina Interna: Estudo-Piloto

“…Assim, tendo em vista aprofundar este conhecimento a nível nacional, Oliveira e colaboradores (2020) avaliaram as potenciais contribuições das principais fontes de informação disponíveis em Portugal na obtenção da BPMH, demonstrando a importância dos registos eletrónicos em saúde, representados nomeadamente pela plataforma de dados da saúde (PDS), na maior exatidão da informação terapêutica, particularmente ao se considerar um período retrospetivo de seis meses ao internamento. 7 Na continuidade deste trabalho, foi nosso objetivo realizar um estudo-piloto de Reconciliação Terapêutica no momento da admissão hospitalar para, a partir dele, identificarmos os recursos necessários para a sua implementação na prática clínica.…”

“…Obtenção do perfil farmacoterapêutico pré-hospitalar e construção da BPMH. Além dos registos hospitalares, foram consultados o Registo de Saúde Eletrónico (RSE) na Plataforma de Dados da Saúde (PDS) num período retrospetivo de seis meses a contar da data de admissão hospitalar, 7 prescrições médicas de ambulatório, listas e sacos de medicação trazidos pelo doente ou das instituições de longa permanência, assim como demais prescrições, planos de Para finalizar esta etapa, o farmacêutico-investigador realizou uma entrevista semiestruturada a todos os participantes (doente/cuidador) com vista à confirmação dos dados obtidos, considerando-se esta informação como sendo a mais exata. Feita a confrontação dos dados obtidos na entrevista com, pelo menos, mais uma das fontes de dados citadas, construímos a BPMH, permitindo a identificação dos medicamentos de uso crónico pré-hospitalar (nome do medicamento, dose, forma farmacêutica, frequência e via de administração).…”

Identification of a Set of Patient-Related Features to Foster Safe Prescribing of Specific Antipsychotics in the Elderly With Dementia

“…Another important aspect is the fact that some PRFs may be available in the nursing records (e.g., blood pressure, weight), which may be missed if prescribers do not look for it when prescribing atypical APs, where the risk of developing metabolic syndrome is high. So, it is important to acknowledge the contribution of different patient information sources to ensure a safe prescribing of such medications (27).…”

Pharmacist-led medication reconciliation on admission to an acute psychiatric hospital unit

“…1 MR is a systematic process to create an accurate list of the patient’s medicines, known as the best possible medication history, and to compare it with the medication instituted at each time of transition of care. 2 , 3 …”

“…1 MR is a systematic process to create an accurate list of the patient's medicines, known as the best possible medication history, and to compare it with the medication instituted at each time of transition of care. 2,3 In many countries, healthcare institutions should have established medication reconciliation policies at patient admission. 4,5 The Prescribing Observatory for Mental Health in the UK, which aims to improve the quality of mental health prescribing practice, reported that medication reconciliation improves the quality of these inpatient health programs in a psychiatric unit.…”