Assessing the quality of medication documentation: development and feasibility of the MediDocQ instrument for retrospective chart review in the hospital setting.

ABSTRACT:

Objective

The medication process requires clear and transparent documentation in patient records. Incomplete or incorrect medication documentation may contribute to inappropriate clinical decision-making and adverse events. To comprehensively assess the quality of in-hospital medication documentation, we developed a retrospective chart review (RCR) instrument. We report on the development process, the feasibility of the instrument and describe our application of the instrument to a sample of patient records.

Design

Cross-sectional study using an RCR instrument to evaluate paper-based, non-standardised prescription and medication administration charts (MediDocQ).

Setting

Two German university hospitals.

Participants

Records from 1361 patients admitted between Ap

SUBMITTER: Hammer A 

PROVIDER: S-EPMC6886911 | biostudies-literature | 2019 Nov

REPOSITORIES: biostudies-literature