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

Medical records are used to facilitate preadmission screening in external referrals to inpatient rehabilitation facilities (IRFs). This study aimed to assess structured medication data completeness in documentation received in these referrals.

Eligible medical records faxed from referring hospitals (due to lack of interoperability) to a Veterans Affairs (VA) hospital for potential rehabilitation unit admission were examined for structured medication data completeness. Medication data elements and formats (e.g., standalone reports with and without lookback periods and lists in progress notes) were evaluated. Subgroup analyses were performed for high-risk medications and data from the most frequently referring hospital. Chi-square analysis was used to evaluate associations between data format and completeness.

Of 105 referrals, 103 contained structured medication data. All data formats had gaps in medication data completeness. Standalone reports with lookback periods had the highest degree of completeness. Chi-square results demonstrated significant associations between data format and completeness across all elements assessed. Subgroup analyses for high-risk medications and data from the most frequently referring hospital showed similar findings, except for non-significant associations between data format and dose element completeness.

Standalone reports with lookback periods have greater medication data completeness compared to other formats used for conveying medication data.