Mersfelder Tracey L, Bickel Ryan J
College of Pharmacy, Ferris State University, Big Rapids, MI 49307, USA.
Am J Health Syst Pharm. 2008 Dec 1;65(23):2273-5. doi: 10.2146/ajhp080013.
The ability of pharmacy students to improve the accuracy of patients' medication histories was studied.
This prospective study was conducted between January and April 2007 at a 424-bed community teaching hospital. Pharmacy students were assigned one or two patients daily admitted to the inpatient internal medicine service and were required to perform a thorough medication history for each. Patients were included in the study if a medication history was performed and recorded on the medication reconciliation form. Students were instructed to obtain medication histories by interviewing the patient, a family member, or both and calling the patient's community pharmacy to verify all medications. If there were any discrepancies between these sources of information and the initial medication reconciliation form, the information was reconfirmed with the patient. Any information obtained by the students that had not already been documented on the medication reconciliation record was updated in the patient's chart.
A total of 326 charts were included in this analysis. Student-obtained medication histories resulted in the addition of previously undocumented prescription medications to 175 charts (53.7%) and nonprescription medications or natural products to 167 charts (51.2%). Calling the patients' community pharmacy helped to identify omissions or discrepancies approximately 75% of the time. Overall, the students improved the accuracy of medication histories for 220 (67%) of the 326 patients.
Pharmacy students' participation in obtaining medication histories improved the completeness and accuracy of patient medication records.
研究药学专业学生提高患者用药史准确性的能力。
这项前瞻性研究于2007年1月至4月在一家拥有424张床位的社区教学医院进行。药学专业学生每天被分配到一两名入住内科病房的患者，并要求为每位患者进行全面的用药史调查。如果用药史已在用药核对表上进行记录，则该患者被纳入研究。学生们被指示通过询问患者、家属或两者来获取用药史，并致电患者的社区药房以核实所有药物。如果这些信息来源与初始用药核对表之间存在任何差异，则与患者再次确认信息。学生获取的任何尚未记录在用药核对记录中的信息都会在患者病历中更新。
本分析共纳入326份病历。学生获取的用药史使得175份病历（53.7%）中新增了之前未记录的处方药，167份病历（51.2%）中新增了非处方药或天然产品。致电患者的社区药房在大约75%的情况下有助于发现遗漏或差异。总体而言，学生提高了326名患者中220名（67%）患者用药史的准确性。
药学专业学生参与获取用药史提高了患者用药记录的完整性和准确性。
