For institutions without a fully integrated EMR, providing a complete and legible discharge medication list is challenging. Medication reconciliation forms must serve the needs of both patient safety goal standards and the patient. In attempting do both, paper forms often do not serve either purpose well.
At our hospital, discharged patients were given the admission medication reconciliation form, with instructions about whether each preadmission medication was to be continued, stopped, or changed. They were also given a copy of the discharge prescription, which listed new and refilled medications. However, the combination of 2 separate forms caused substantial patient confusion, and the information written was often not legible. We therefore designed and implemented a new computerized platform for documenting the discharge medication list, separate from the admission form.
UCSD has a computerized discharge instruction module with discharge instructions, follow‐up appointments, and hospital course. Screens were added to this computerized wortt flow To prompt the discharging provider for discharge medication information. Separate fields were created for (1) unchanged preadmission medications, (2) new medications at discharge, (3] medications with dosing changes, and (4) medications to be stopped. Implementation of this change was made in June 2009, with a large educalional campaign integrated inlo the computer training of new interns. Baselire discharge medication information quality was assessed by a closed chert re‐ view of 48 cases. Although the paper forms had columns for drug name, dose, route and frequency, only 75% of the baseline charts reviewed had complete information listed. Closed chart review postimplcmcntation was conducted in August 2003 [429 cases) and November 2009 [385 cases); these charts were evaluated for The presence of preadmission medications, new medications, and whether the medication informalion formaT was complete. The August and November results were compared using 2‐tailed t tests; results from the chart reviews are shown in Table 1.
Following enhancemenl of our computerized discharge information module, medication information quality was comparable to that of The preimplemenTaTion period, but medication lists were legible and easily retrievable in the medical record. Providers were more compliant with entering new and preadmission discharge medication names but less complianl with lisling dose, route, and frequency. Ongoing provider education after implementation may be necessary to sustain and improve adherence to medication reconciliation standards.
B, Clay, none; B, Huang, none.
To cite this abstract:Clay B, Huang B. Structured Screen Prompts in a Computerized Discharge Instruction Module and Adherence to Discharge Medication Reconciliation Standards. Abstract published at Hospital Medicine 2010, April 8-11, Washington, D.C. Abstract 160. Journal of Hospital Medicine. 2010; 5 (suppl 1). https://www.shmabstracts.com/abstract/structured-screen-prompts-in-a-computerized-discharge-instruction-module-and-adherence-to-discharge-medication-reconciliation-standards/. Accessed March 29, 2020.