Completeness and Interpretability of Inpatient Pharmacist Documentation for Patients With Physician-Documented...

Routine inpatient pharmacist records can support continuity of care and service evaluation, but their usefulness depends on whether documented values are complete and clinically interpretable and whether the documentation distinguishes domains that were assessed and found negative from those that were not assessed or not documented. The objectives of this study were to describe medication documentation and asthma-management issues recorded by pharmacists for hospitalized patients with physician-documented asthma and to assess the structural completeness and interpretability of selected structured and free-text documentation fields.

This retrospective documentation audit included 32 pharmacist-documented admission records from Sisaket Hospital, Thailand, from October 2024 through September 2025. To avoid duplicate observations from the same patient, the earliest eligible record for each hospital number was retained, resulting in 27 patients. Structured medication, comorbidity, and prior-exacerbation fields were audited for explicit values and missingness. Free-text notes were coded with an operational codebook by a primary coder and one of two alternating second coders, with disagreements resolved by consensus. Descriptive statistics and binomial 95% confidence intervals (CIs) were reported.

The mean age was 61.19 ± 15.50 years, and 21 of 27 patients (77.78%) were female. All audited medication fields contained explicit binary responses, all comorbidity fields contained explicit text, and the prior-exacerbation field contained a numeric value for all patients. Pre-admission inhaled corticosteroid/long-acting beta2-agonist and long-acting muscarinic antagonist therapy were recorded in 19 of 27 (70.37%) and nine of 27 (33.33%) records, respectively. Both were positive in separate pre-admission fields in eight of 27 records (29.63%), although the explicit triple-therapy field was negative in every record. Pharmacist notes documented trigger- or exposure-related wording in 16 of 27 records (59.26%; 95% CI, 38.80%-77.61%), inhaler technique issues in 11 of 27 (40.74%; 95% CI, 22.39%-61.20%), and poor adherence wording in nine of 27 (33.33%; 95% CI, 16.52%-53.96%). One stand-alone "No" entry was unclassifiable because its original prompt was unavailable.

The selected records contained clinically relevant asthma-management wording, but the documentation structure limited the reproducibility of interpretation. The findings are documentation frequencies rather than hospital prevalence estimates, and do not establish the effectiveness of pharmacist care. Three-state assessment fields, separated exposure categories, and explicit active-regimen fields are needed before routine documentation can reliably support service evaluation or outcome research.