title: Identifying discrepancies in electronic medical records through pharmacist medication reconciliation.
abstract: OBJECTIVE
  To describe the types and causes of medication discrepancies in the electronic medical record identified by pharmacist medication reconciliation during outpatient medical visits and to identify patient characteristics associated with the presence of discrepancies.
  
  
  METHODS
  Observational case series study.
  
  
  METHODS
  Indigent primary care clinic in Pittsburgh, PA, from April 2009 to May 2010.
  
  
  METHODS
  219 adults presenting for follow-up medical visits and self-reporting medication use.
  
  
  METHODS
  Medication reconciliation as part of patient interview and concurrent chart review.
  
  
  METHODS
  Frequency, types, and reasons for medication discrepancies and demographic variables, patient knowledge, and adherence.
  
  
  RESULTS
  Of 219 patients interviewed, 162 (74%) had at least one discrepancy. The most common type of discrepancy was an incorrect medication documented on the chart. The most common reasons included over-the-counter (OTC) use of medications and patients not reporting use of medications. The presence of one or more medication discrepancies was associated with the use of three or more medications. Patient factors such as gender, age, and race were not associated with discrepancies. Patients able to recall the strength for more than 75% of their medications had fewer discrepancies, while knowledge of the medication name, indication, or regimen had no association with discrepancies.
  
  
  CONCLUSIONS
  Pharmacists play a critical role in identifying discrepancies between charted medication lists and self-reported medication use, independent of adherence. Inaccuracies in charted medications are frequent and often are related to use of OTC therapies and lack of communication and documentation during physician office visits. Knowledge of patient-related variables and other reasons for discrepancies may be useful in identifying patients at greatest risk for discrepancies and interventions to prevent and resolve them.
authors.affiliation: Division of Clinical, Social and Administrative Sciences, Mylan School of Pharmacy, Duquesne University, Pittsburgh, PA, USA. run-yona@duq.edu
authors.forename: Autumn L
authors.initials: AL
authors.lastname: Stewart
authors.forename: Kevin J
authors.initials: KJ
authors.lastname: Lynch
mesh_terms: D000328:Adult; D000368:Aged; D003142:Communication; D057286:Electronic Health Records / Q000592:standards*; D005260:Female; D005500:Follow-Up Studies; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D008297:Male; D055118:Medication Adherence; D008508:Medication Errors / Q000517:prevention & control*; D059065:Medication Reconciliation / Q000379:methods*; D008875:Middle Aged; D004366:Nonprescription Drugs / Q000627:therapeutic use; D010414:Pennsylvania; D010593:Pharmaceutical Services / Q000458:organization & administration; D010595:Pharmacists / Q000458:organization & administration*; D011203:Poverty; D011320:Primary Health Care / Q000458:organization & administration; D024382:Professional Role; D055815:Young Adult
chemical_list: D004366:Nonprescription Drugs