Evaluation of Partnered Pharmacist Charting at Admission and Discharge

Partnered pharmacist charting: on admission to selected General Medical or Emergency Short Stay Units at a major tertiary institution (Alfred Hospital), patients' regular medications will be charted by a credentialled clinical pharmacist, and endorsed by a medical officer. At time of discharge from hospital, patients from selected General Medicical units will have the medication management section of their discharge summary completed by a credentialed clinical pharmacist, and endorsed by a medical officer. Procedure: Medication reconciliation on admission and discharge medication counselling both include face-to-face sessions with the patient as routine care. Admission medication charting and discharge summary completion do not replace this, nor do they add extra patient contact. Admission: The pharmacist takes a medication history (routine care), performs VTE risk assessment, has a discussion with the admitting medical officer about current problems and the medication management plan is agreed upon. Pre-admission medications and VTE prophylaxis are charted by the pharmacist; followed by a discussion between the treating nurse and pharmacist about the plan, including urgent medications to be administered, drug-related monitoring and reasons for any changes. Discharge: Following discharge medication and prescription review (routine care) and discussion with the medical team, the pharmacist electronically enters the following into the medication management section of the discharge summary: -current list of all medications the patient should be taking on discharge, listed according to whether they are new (including indication), changed (including reason), or unchanged. -a list of all medications ceased during admission, including reasons -medication allergies -smoking status, and management during admission -actions required by the GP, including medications requiring review Once complete, the discharge summary is reviewed and endorsed by the discharging medical officer Admission medication charting takes approximately 15-20 minutes depending on the number and complexity of medications Discharge summary completion takes approximately 5-15 minutes depending on the number and complexity of medications. The duration of the observation period is four months. Based on the allocation of units to interventions, patients will receive either the admission or discharge intervention, but not both, per admission. Patients readmitted to hospital during the study period may be allocated to receive the same or different intervention during their next admission, as each admission is considered a new event. For patients in ESSU, only the admission charting intervention is applicable. Regular auditing of medication charts and discharge summaries was undertaken. Charts or summaries completed by a medical officer in the pharmacist-arm units were excluded (including charts completed outside of pharmacist working hours).