Accuracy and Completeness of Medication Histories in Patients in Medical Admission Ward at the University Teaching Hospital

Background: Quality documentation of medication histories at the time of hospitaladmission with regard to accuracy and completeness is not documented at the University Teaching Hospital (UTH), in Zambia. The aim of our study was to assess the accuracy and completeness of medication histories obtained in patients upon hospital admission. Materials and Methods: We conducted a prospective cross-sectional study at the medical admission ward, University Teaching Hospital, over a period of 3months. Our study enrolled 322 patients admitted to this ward who were above 18 years of age and were able to communicate verbally, if not, were accompanied by a caregiver. Clinical records of these patients were screened to review allmedications the patient was taking and patients/caregivers were interviewed to obtain acomplete medication history. All information obtained from patients through interviews was compared with medications recorded in the patient’s clinical records at the time of admission to the hospital. The Statistical Package for Social Sciences(SPSS) version 22 was used for all statistical calculations. Results: Of 287 clinical records, 175 (61%) incidents of inaccurate medication histories at the time of admission were identified and that medication histories in clinical records of patients were incomplete or poorly documented. Conclusion: Our study shows that 61% of medication histories in patients at the time of admission to hospitals are inaccurate. Quality documentation of medication histories in clinical records at the time of hospital admission is poor.