Comunicação relacionada ao uso de medicamentos por enfermeiros, farmacêuticos e médicos : uma análise dos registros em prontuários clínicos

Abstract

Recording medication information is an important part of all clinical practice. Although health professionals need to assess information about the patient’s medication, there is a recall bias and thus, medication histories are often incomplete within medical records upon hospital stay. Thus, the aim of this study was to characterize the documentation regarding physicians, nurses, and pharmacist’s report of inpatient medication information on medical records. Methods. A cross-sectional study was performed in the medical records of hospitalized patients that were admitted in a teaching hospital in Northeast Brazil between December 2016 and February 2017. Data sources in each patients’ medical record, including the nurse, pharmacist and physician’s notes, were subsequently examined to evaluate the report of information regarding medication information. Moreover, an analysis of communication failures was conducted through all medical records. The study was authorized by the Hospital Board and the Research Ethics Committee under CAAE number 08125912.5.0000.0058. Results. Two hundred and two patients with an average age of 51.48 ± 16.42 (19–97) years were included in the study. There was no record of a patient report on medication allergies and intolerances in 44 (21.9%) nursing notes, 8 (22.9%) pharmacist notes and 54 (26.8%) physician notes. Also, 1,588 medication changes were found in all medical records, where only 390 (24.5%) of those had a documented reason. Still, it was possible to identify 485 communication failures regarding medication use within the hospital stay in 65.3% (n=132) of the medical records. Conclusions. The results revealed that documentation of medication information on medical records are often poor and incomplete. Therefore, future studies should investigate the quality of recording medication information to enhance the communication skills of health professionals and ensure patient safety in all transitional points of care.