title: Documentation of medication changes in inpatient clinical notes: an audit to support quality improvement.
abstract: OBJECTIVE
  To describe completeness and accuracy of recording medication changes in progress notes during psychiatric inpatient admissions.
  
  
  METHODS
  A retrospective audit of records of 54 randomly selected psychiatric admissions at a metropolitan tertiary hospital. Medication changes recorded on National Inpatient Medication Chart (NIMC) were compared to documentation in the clinical progress records and assessed for completeness against seven quality criteria.
  
  
  RESULTS
  With between one and 32 medication changes per admission, a total of 519 changes were recorded in NIMCs. Just over half were documented in progress notes. Psychotropic and regular medications were more frequently charted than 'other' and 'if required' medications. Documentation was seldom comprehensive. Medication name was most frequently documented; desired therapeutic effect or potential adverse effects were rarely documented. Evidence of patient involvement in, and an explicit rationale for, a change were infrequently recorded.
  
  
  CONCLUSIONS
  Revealing substantial gaps in communication about medication changes during psychiatric admission, this audit sheds light on a previously undescribed source of medication error, warranting attention. Further research is needed to examine barriers to best practice, to support design and implementation of quality improvement activities but in the interim, attention should be addressed to development and articulation of content and procedures for documentation.
authors: Team Leader Pharmacy Mental Health, Metro North Hospital and Health Service, Brisbane, QLD, Australia.
authors: Elsie
authors: E
authors: Peusschers
authors: Pharmacist, The Prince Charles Hospital, Mental Health, Metro North Hospital and Health Service, Brisbane, QLD, Australia.
authors: Jaryth
authors: J
authors: Twine
authors: Professor of Mental Health Services Research, Griffith University, Brisbane, QLD, Australia, and; Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
authors: Amanda
authors: A
authors: Wheeler
authors: Clinical Director, Metro North Hospital and Health Service, Brisbane, QLD, Australia.
authors: Vikas
authors: V
authors: Moudgil
authors: Team Leader Pharmacy Mental Health, Metro North Hospital and Health Service, Brisbane, QLD, AustraliaPharmacist, The Prince Charles Hospital, Mental Health, Metro North Hospital and Health Service, Brisbane, QLD, AustraliaProfessor of Mental Health Services Research, Griffith University, Brisbane, QLD, Australia, and; Faculty of Medical and Health Sciences, University of Auckland, Auckland, New ZealandClinical Director, Metro North Hospital and Health Service, Brisbane, QLD, AustraliaPrincipal Research Fellow, Metro North Hospital and Health Service, Brisbane, QLD, and; Griffith University, Brisbane, QLD, Australia susan.patterson@health.qld.gov.au.
authors: Sue
authors: S
authors: Patterson
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D007297:Inpatients; D008297:Male; D008485:Medical Audit; D008499:Medical Records / Q000592:standards*; D008508:Medication Errors / Q000517:prevention & control*; D008875:Middle Aged; D058996:Quality Improvement; D012189:Retrospective Studies; D055815:Young Adult
keywords: audit; documentation; medication safety; standards