Retrospective assessment of clinical pharmacist medication sheets documentation completeness from a sample of Iraqi health care units

Abstract EN

Background & Aim Medical records documentation is an important legal and professional requirement for all health professionals to ensure that the medications prescribed for patients contribute to the best possible health outcomes.

The main objective was to assess the documentation completeness level of the medication sheets in the different inpatient wards of Iraqi hospitals, also to identify trends of clinical pharmacist intervention towards problems related to drugs, and to estimate physician’s acceptance status of the proposed intervention.

Method A retrospective study was conducted in a number of randomly selected hospitals as a multicenter; the sample consisted of number of randomized medication summary sheets per ward, recorded during the medication order validation process and drug-related problems were identified.

Patient’s demographic characteristics, drugs administered, drug-related problems description, pharmacist’s recommendations, and whether or not the recommendations were accepted by the physician or not were recorded.

Result A total number of (562) medication sheets collected from multiple wards of different hospitals, pharmacist intervention represent (23.5%) of total medication sheets across multiple wards from 3 hospitals.

Medication sheets of the emergency and CCU included the majority of pharmacist interventions (64.4%), followed by medication sheets of a surgical ward (18.9%), and the least intervention was found among medication sheets of the internal medicine ward (16.6%).

Drug-related problems that may arise in hospital settings are mainly dispensing errors (32.65%), unavailability of an indicated drug (15.64%).

A total of 295 counseling and recommendations to patients and health care providers at the physician, nursing staff levels were implemented and documented.

This retrospective pilot study confirmed the obvious incompleteness of documenting the majority of clinical pharmacist medication sheets for the inpatient particularly in the surgery ward.