INTRODUCTION
Effective communication regarding the use of medications in hospital environments is a dynamic and complex process that contributes to the promotion of patient safety.1 Regarding communication between the healthcare team, Manias et al. (2016) highlights that when patient information is complete, the continuity of care can be ensured, especially at transition points of care.2
In this context, the medical record should be the main document that mirrors the patient’s history, from hospital admission to discharge, allowing the continuity of care.3,4 Mathioudakis et al. (2016) point out that accurate medical record keeping is integral to good professional practice and the delivery of quality healthcare.5 According to these authors, medical records must describe treatment details and future treatment recommendations besides every medication administered, prescribed or renewed and any drug allergies.
Recent evidence suggests that when the medical record is not well documented, the transfer of information among healthcare professionals may be impaired.6 Communication failure, defined as a flaw in the content, audience, occasion or purpose of the communication act, has been widely reported regarding the use of medications.4,7–10 Furthermore, documentation gaps can cause medication errors, such as unintended medication discrepancies. These occur when there is a change in the pharmacotherapy without clinical justification in the transition points of care, or when the intentionality of the change is not recorded.11,12Thus, medication reconciliation emerges as the most effective strategy to solve such issues.13–15
The literature points out challenges related to the implementation and consolidation of medication reconciliation, with the quality and reliability of the recording of medication information described as challenges still to be overcome.8,16–18 Ideally, all medications that the patient uses before, during and after hospitalization should be documented in the medical record, as well as any changes and justifications for them, improving the communication between the healthcare team.3,19 Complete documentation ensures that relevant information for healthcare decision making is available, providing effective evaluation and monitoring of treatment, decreasing episodes of medication omissions and therapeutic duplicity.20,21
There are legal issues to ensure good quality documentation recommendations for the United Kingdom, Australia, most of the United States, France and other countries.5 In Brazil, studies evaluating the quality and content of medical records are still scarce. Lack of research in this area means that it is difficult to understand how information contained in medical records affects assessment of adverse events and medication errors.22–25 Thus, the present study aimed to describe the documentation in medical records regarding the medication use process by pharmacists, physicians and nurses on admission, hospital stay, and hospital discharge.