Pharmacy student engagement in the evaluation of medication documentation within an ambulatory care electronic medical record

An abundance of literature supports the benefits of electronic medical records (EMR) for improving overall healthcare quality. Identifying preventative care opportunities, reducing medical and medication related errors and incorporating clinical practice guidelines are just a few attributes of EMR implementation. The goals of this study were to engage experiential pharmacy students in the assessment of medication related documentation discrepancies in a newly implemented EMR system and to provide exposure to various aspects of conducting research.

Pharmacy students screened patient charts over a three-month period to identify documentation discrepancies, including omissions of medications and medical problems and duplication of medications. Students conducted medication reconciliation for a total of one-hundred thirty-four patients.

Medication omissions were identified for 46% of patients, medical problem omissions were identified for 38% of patients, and thirty-two duplicate medications were identified.

Engaging pharmacy students in the quality improvement project afforded an interactive learning experience, highlighting firsthand the challenges associated with electronic documentation and the associated potential negative implications to patient care. Additionally, students gained exposure to various components of research including data collection, assessment, entry, analysis and future implications.