Steven Bou, Heide Klumpp, Amanda Kozlowski, Sharon Espinoza
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引用次数: 0
Abstract
Objective: 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.
Design: 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 (eg, 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. χ 2 analysis was used to evaluate associations between data format and completeness.
Results: 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. χ 2 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 nonsignificant associations between data format and dose element completeness.
Conclusions: Standalone reports with lookback periods have greater medication data completeness compared with other formats used for conveying medication data.
期刊介绍：
American Journal of Physical Medicine & Rehabilitation focuses on the practice, research and educational aspects of physical medicine and rehabilitation. Monthly issues keep physiatrists up-to-date on the optimal functional restoration of patients with disabilities, physical treatment of neuromuscular impairments, the development of new rehabilitative technologies, and the use of electrodiagnostic studies. The Journal publishes cutting-edge basic and clinical research, clinical case reports and in-depth topical reviews of interest to rehabilitation professionals.
Topics include prevention, diagnosis, treatment, and rehabilitation of musculoskeletal conditions, brain injury, spinal cord injury, cardiopulmonary disease, trauma, acute and chronic pain, amputation, prosthetics and orthotics, mobility, gait, and pediatrics as well as areas related to education and administration. Other important areas of interest include cancer rehabilitation, aging, and exercise. The Journal has recently published a series of articles on the topic of outcomes research. This well-established journal is the official scholarly publication of the Association of Academic Physiatrists (AAP).
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