Table 2. Medication-related information present in the clinical notes of pharmacists, physicians and nurses of a teaching hospital in Northeast Brazil. Table 2. Medication-related information present in the clinical notes of pharmacists, physicians and nurses of a teaching hospital in Northeast Brazil. Table 2. Medication-related information present in the clinical notes of pharmacists, physicians and nurses of a teaching hospital in Northeast Brazil. Table 2. Medication-related information present in the clinical notes of pharmacists, physicians and nurses of a teaching hospital in Northeast Brazil.
Variables analyzed
Nurses’ clinical notes
Pharmacists’ clinical notes
Physicians’ clinical notes
n (%) n (%) n (%)
Total number of records 201 (99.5%) 35 (17.3%) 202 (100%)
HOSPITAL ADMISSION
Written record of allergies and/or adverse drug reactions
157 (77.7%)
27 (13.4%)
148 (73.3%)
Written record of the use of medications prior to admission
56 (27.7%)
28 (13.9%)
167 (82.7%)
Patient denies the use of medications prior to admission
12 (5.9%)
5 (2.5%)
37 (18.3%)
Dose
8 (4.0%)
16 (7.9%)
102 (50.5%)
Frequency
6 (3.0%)
15 (7.4%)
90 (44.5%)
Treatment duration
1 (0.5%)
1 (0.5%)
13 (6.4%)
HOSPITAL STAY
Non-conformities related to medication use process 48 (23.7%) 11 (5.4%) 97 (48.0%)
Referrals to other professionals suggesting interventions in pharmacotherapy 28 (13.8%) 10 (4.9%) 32 (15.8%)
HOSPITAL DISCHARGE
Report of medications use after hospitalization
1 (0.4%)
0 (0.0%)
93 (46.0%)
Counter-referrals
1 (0.4%)
0 (0.0%)
161 (79.7%)