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Changing the medication documentation process for discharge: impact on clinical routine and documentation quality-a

Benedict Morath1,2, Anette Lampert1,2, Franziska Elisabeth Glaß1

  • 1Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Baden-Württemberg, Germany.

European Journal of Hospital Pharmacy : Science and Practice
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PubMed
Summary

Implementing a new medication documentation process improved documentation quality to meet legal standards. However, this led to increased physician workload, highlighting the need for support in medication management workflows.

Keywords:
discharge managementelectronic prescribingimplementation researchmedication documentationprocess evaluation

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Area of Science:

  • Health Services Research
  • Clinical Pharmacy
  • Healthcare Management

Background:

  • German legal requirements mandate improved medication documentation for hospital discharge.
  • A best-practice process was developed and implemented to address these requirements.
  • Assessing the impact on medication documentation quality and workflows is crucial.

Purpose of the Study:

  • To evaluate the impact of a new best-practice medication documentation process on quality and workflows.
  • To measure adherence to the new process and identify workload changes.
  • To analyze the effect on clinical routine in a university hospital setting.

Main Methods:

  • Workflow observation and employee interviews in seven hospital departments.
  • Analysis of medication documentation quality using predefined criteria.
  • Measurement of adherence, workload, and responsibility shifts before and after implementation.

Main Results:

  • All departments met legal requirements post-implementation, with medication documentation quality improving significantly.
  • Mean adherence to the best-practice process was 77%, with variations across departments.
  • Increased process steps led to higher workload, primarily for physicians and pharmacists.

Conclusions:

  • The new process enhanced medication documentation quality, fulfilling legal mandates.
  • Increased workload for physicians may impact time available for patient care.
  • Interprofessional support and technological tools are needed to optimize medication documentation and continuity of care.