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Related Experiment Video

Updated: Jul 6, 2026

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Preadmission Medication Data Completeness in External Referrals to a Rehabilitation Unit: An Observational Study.

Steven Bou1, Heide Klumpp2, Amanda Kozlowski3

  • 1Rehabilitation Service, Edward Hines, Jr. VA Hospital; Department of Physical Medicine and Rehabilitation, Rosalind Franklin University of Medicine and Science.

American Journal of Physical Medicine & Rehabilitation
|April 10, 2026
PubMed
Summary

Structured medication data completeness in referrals to inpatient rehabilitation facilities (IRFs) was assessed. Standalone reports with lookback periods demonstrated the most complete medication data, improving patient care transitions.

Keywords:
CommunicationHealth Care TransitionsHealth Information InteroperabilityHospitalsMedication ReviewRehabilitation

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Area of Science:

  • Health Informatics
  • Rehabilitation Medicine
  • Data Management

Background:

  • Medical records are crucial for preadmission screening in inpatient rehabilitation facilities (IRFs).
  • External referrals often lack interoperability, necessitating data transfer via fax.
  • Structured medication data completeness is vital for safe patient transitions.

Purpose of the Study:

  • To evaluate the completeness of structured medication data in external referrals to IRFs.
  • To compare the completeness of medication data across different documentation formats.
  • To identify optimal formats for conveying medication information.

Main Methods:

  • Examined medical records from 105 referrals to a Veterans Affairs (VA) hospital.
  • Assessed structured medication data completeness in various formats (standalone reports with/without lookback periods, progress note lists).
  • Utilized Chi-square analysis to determine associations between data format and completeness, including subgroup analyses for high-risk medications.

Main Results:

  • 103 of 105 referrals contained structured medication data, but all formats exhibited completeness gaps.
  • Standalone reports with lookback periods showed the highest medication data completeness.
  • Significant associations were found between data format and completeness, except for dose element completeness in specific subgroups.

Conclusions:

  • Standalone reports incorporating lookback periods are superior for medication data completeness in IRF referrals.
  • Improving data format can enhance the accuracy of medication information during patient transfers.
  • Standardizing documentation formats is recommended to ensure comprehensive medication data.