Clinical Pharmacist Interventions and Barriers for Documenting these Interventions at King Faisal Specialist Hospital and Research Center

Al-Aqeel, Sinaa; Al-Anizi, Rawan; Alkortas, Delal; Al-Fadel, Nouf; Korayem, Ghazwa B.

doi:10.4197/med.19-1s.6

Cited by 3 publications

(12 citation statements)

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“…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][41][42][43]31,32,[34][35][36][37][38][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.…”

Section: Discussionmentioning

confidence: 99%

Written communication about the use of medications in medical records during patients' hospitalization in Brazil

Santos¹,

Carvalho²,

Macêdo³

et al. 2021

Preprint

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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.

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Section: Discussionmentioning

confidence: 99%

Written communication about the use of medications in medical records during patients' hospitalization in Brazil

Santos¹,

Carvalho²,

Macêdo³

et al. 2021

Preprint

View full text Add to dashboard Cite

show abstract

“…In light of this view, it becomes unclear what pharmacists’ roles are in a multiprofessional patient care environment, since the gaps of documentation prevent proper analysis of their interventions. This omission may impair patient care, considering that the integration of pharmacists into core healthcare teams facilitates better health outcomes, better team decision making regarding medication use, improved continuity of care and patient safety 2,29,31,32,34‐43 . Most nurses’ and pharmacists’ notes did not present information on the medication use at admission and hospital discharge, especially the absence of treatment duration.…”

Section: Discussionmentioning

confidence: 99%

“…This omission may impair patient care, considering that the integration of pharmacists into core healthcare teams facilitates better health outcomes, better team decision making regarding medication use, improved continuity of care and patient safety. 2,29,31,32,[34][35][36][37][38][39][40][41][42][43] 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 hospitalisation, lead to treatment interruptions and compromise patient safety.…”

Section: Discussionmentioning

confidence: 99%

Written communication about the use of medications in medical records in a Brazilian hospital

Santos

Silvestre

Macêdo

et al. 2021

Int J Clinical Practice

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Background Effective communication regarding the use of medications in hospital environments is a process that contributes to patient safety. Despite its importance, written communication about the medication use process 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 at 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 hospitalised for at least 48 hours. Clinical notes made by pharmacists, physicians and nurses were examined at three transition points of care. Data were collected using a questionnaire relating to the use of medications prior to hospital admission, changes in the prescribed medications during the hospital stay and discharge, as well as prescription non‐conformities. Communication failures between the three healthcare professional groups were analysed and classified. The study was authorised by the Hospital's Board of Directors and approved by the Research Ethics Committee of the Federal University of Sergipe. Results This study included 202 medical records of 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 9 (25.0%) pharmacist notes. Moreover, 1,588 changes in prescriptions were identified during data collection, and 1,198 (75.4%) of these were unjustified. Conclusion Medication‐related information in medical records was incomplete and inconsistent in the clinical notes of the three studied professions, especially in pharmacists' documentation. Future studies should focus on investigating the consequences of interprofessional communication in patient care.

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“…21,28 Regarding the classification methods, most of them (60%) were in-house developed, without any reference to the literature. 6,17,21,27,34,45 Others (40%) were a result of in-house modifications and adaptations of previous published studies. 18,22,28,39 The amount of information documented and the number of categories used for classifying PIs was highly variable and is detailed in Table 2.…”

Section: In-house Developed Documentation/ Classification Methodsmentioning

confidence: 99%

“…All studies were descriptive, with three prospective 21,22,27 and six retrospective, 6,17,18,28,34,39,45 while one also included a survey. 17 Most of the studies were from the Middle East (Saudi Arabia, 6,17,22 Iran, 21 Lebanon 28 and Oman 18 ), two were from the United States, 27,34 one from Germany 39 and the other one from Australia. 45 For their own use, the hospitals or private health systems developed the internal documentation and/or classification systems mentioned in these studies.…”

Section: In-house Developed Documentation/ Classification Methodsmentioning

confidence: 99%

Documentation and classification of hospital pharmacist interventions: A scoping review

Machado,

Falcão,

das Cavaco

2023

Brit J Clinical Pharma

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The practice of documenting pharmacists’ interventions (PIs) has been endorsed by many hospital pharmacists’ societies and organizations worldwide. Current systems for recording PIs have been developed to generate data on better patient and healthcare outcomes, but harmonization and transferability are apparently minimal. The present work aims to provide a descriptive and comprehensive overview of the currently utilized PIs documentation and classification tools contributing to increased evidence systematization.A systematic literature search was conducted in PUBMED, Scopus, Web of Science, and CINAHL. Studies from 2008, after the release of the Basel Statements, were included if interventions were made by hospital or clinical pharmacists in a global hospital setting. Publications quality assessment was accomplished using the Mixed Methods Appraisal Tool (MMAT).A total of 26 studies were included. Three studies did not refer to the documentation/classification method, ten used an in‐house developed documentation/classification method, seven used externally developed documentation/classification tools, and six studies described method validation or translation.Evidence confirmed that most documentation/classification systems are designed in‐house, but external development and validation of PI systems to be used in hospital practice is gradually increasing. Reports on validated PIs documentation/classification tools that are being used in hospital clinical practice are limited, including countries with advanced hospital pharmacy practice. Needs and gaps in practice were identified. Further research should be conducted to understand why using validated documentation/classification methods is not a disseminated practice, knowing patients’ and organizational advantages.

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Clinical Pharmacist Interventions and Barriers for Documenting these Interventions at King Faisal Specialist Hospital and Research Center

Cited by 3 publications

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Written communication about the use of medications in medical records during patients' hospitalization in Brazil

Written communication about the use of medications in medical records during patients' hospitalization in Brazil

Written communication about the use of medications in medical records in a Brazilian hospital

Documentation and classification of hospital pharmacist interventions: A scoping review

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