Documentation of drug interchange in the medical record

The hospital medical record has become increasingly exposed to retrospective audits by third party insurers, quality assessment studies, and billing inquiries. As a result, the demand for complete documentation in the record has steadily increased during the past few years. Institutional medical practices are subject to a variety of regulations and standards. Economic pressures are continually exerted on hospitals for cost reduction measures, which include patient drug costs. While hospitals have engaged in a variety of methods of drug interchange to reduce costs, documentation procedures for interchange are not specifically regulated. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) appears to be the only source for applicable regulations regarding medical record documentation. With respect to therapeutic drug interchange, few guidelines exist to "legalize" this common practice. A procedure to provide the physician's informed consent for therapeutic interchange is explained. This article will focus on drug interchange notification procedures for non-teaching community hospitals. Legalities, practicalities, and regulations for medical record documentation are addressed. In addition, suggestions for the documentation of drug interchange are proposed.