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.