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MEDICATION HISTORY DOCUMENTATION IN REFERRAL LETTERS OF CHILDREN PRESENTING AT THE EMERGENCY UNIT OF A TEACHING
K A Oshikoya1, M U Orji2, I A Oreagba2
1Dept. of Pharmacology, Lagos State University College of Medicine, Ikeja, Lagos, Nigeria.
Insights
Referral letters frequently lack essential patient information, particularly medication history, impacting care continuity. Standardized guidelines are needed to improve documentation in Nigerian teaching hospitals.
Area of Science:
- Pediatric Emergency Medicine
- Health Information Systems
- Clinical Documentation
Background:
- Referral hospitals often lack comprehensive patient care and medication details from referring facilities.
- Inadequate information transfer hinders effective patient management and continuity of care.
Purpose of the Study:
- To evaluate the completeness of referral letters for pediatric patients at a Nigerian teaching hospital's emergency room.
- Specifically assess the accuracy and inclusion of medication history in these referral documents.
Main Methods:
- A pro forma was used to extract data from referral letters for 100 pediatric patients over three months.
- Information on demographics, diagnoses, vital signs, treatments, and medication history was collected.
- Parental interviews supplemented medication history data.
Main Results:
- Referral letters frequently omitted crucial data, including gender (30%) and diagnoses (12%).
- Significant omissions were noted in weight (82%), vital signs (57%), physical examination findings (44%), treatment details (92%), and medication history (71%).
Conclusions:
- Referral letters to this tertiary care hospital in Lagos, Nigeria, often lack complete medication history and other vital patient data.
- Implementing standardized referral guidelines could significantly improve documentation quality, especially for medication history.
Background:
Medical literature has demonstrated that referral hospitals often receive inadequate information about the care and medications their patients received from referring hospitals.
Objective:
This study aimed to assess the completeness of referral letters, especially the medication history, for patient presenting at the children emergency room of a teaching hospital in Lagos, Nigeria.
Method:
A pro forma form was developed to obtain from the referral letters the demographic information of children referred to the emergency room of the Lagos University Teaching Hospital (LUTH), Idiaraba, over a period of three months. The nature of the referring centre, tentative diagnoses made at the referring centre, duration of illness prior to referral, vital signs and physical examination findings, investigation results, and treatment given were also extracted from the letters. In addition, we extracted from the letters the name, dosage, frequency and duration of use of medicines administered at the referring centres. Parents were also interviewed about the details of medicines used prior to presentation of their child at the referring centres.
Results:
Among those referred with a letter, 100 patients met the inclusion criteria and constituted those evaluated in this study. Most of the patients were referred from general hospitals (31%), another tertiary hospital (29%), and private hospitals/clinics (24%). Gender (30%) and tentative diagnoses (12%) were omitted in the referral letters. However, information about the weight (82%), vital signs (57%), physical examination findings (44%), treatment given (92%), and medication history (71%) were much more omitted in the referral letters.
Conclusion:
Medication history as well as many other data points is infrequently reported in referral letters to a tertiary care hospital in Lagos, Nigeria. Standard referral guidelines may be useful to improve documentation of medication history.
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