title: Medication counseling: analysis of electronic documentation using the clinical care classification system.
abstract: Medication counseling is a central aspect of medication safety. Counseling refers to the process of informing, advising and administering medication to help patients manage their medication regimen. This pilot study examined 379 descriptions of medication counseling carried out in surgical care and documented in an electronic patient record system by using the Clinical Care Classification System. The objective was to identify counseling methods and to evaluate the need for additional counseling descriptor codes in the record. Eleven counseling methods were identified and the data were classified according to counseling methods with and without documentation of the nature of the interaction with patients. There were no descriptions of the nature of counseling conducted in 127 of the documented entries. These results can be used when developing the documentation of medication care in electronic patient records.
authors.affiliation: Department of Health and Social Management, University of Eastern Finland, Kuopio, Finland. kaija.saranto@uef.fi
authors.forename: Kaija
authors.initials: K
authors.lastname: Saranto
authors.forename: Jacqueline
authors.initials: J
authors.lastname: Moss
authors.forename: Virpi
authors.initials: V
authors.lastname: Jylhä
mesh_terms: D037001:Directive Counseling / Q000706:statistics & numerical data*; D004282:Documentation / Q000145:classification*; D057286:Electronic Health Records / Q000706:statistics & numerical data*; D005387:Finland; D008510:Medication Systems, Hospital / Q000706:statistics & numerical data*; D010353:Patient Education as Topic / Q000379:methods* / Q000706:statistics & numerical data*; D010593:Pharmaceutical Services / Q000706:statistics & numerical data*; D014600:Utilization Review