Treatment chart review or Medication Chart Review

Definition, goal and procedure

Definitions

Treatment chart: There are several synonyms for treatment chart such as medication chart, patient chart, patient’s medical chart, medical records and health record. A treatment chart is a confidential medical record of individual patients that contains systemic documentation of clinical and medical history. Medical history (Clinical conditions) includes past and present health status, diagnoses, medication, allergies, surgeries, immunisation and other important information.

The goal of the treatment chart: It serves as both medical and legal documents related to an individual’s medical history and caregivers’ involvement. The medical chart is an important document for healthcare professionals to provide high-quality and continuous care to patients. It also facilitates communication and coordination among healthcare providers. It ensures patient safety by reducing medication errors.

Treatment chart review:

“Treatment chart review is a process to evaluate patients’ medical history to access the quality of medical care provided to identify improvement in healthcare delivery”. “Treatment chart review is a systemic evaluation of the patient's medication management to optimise patient outcome”.

Ideally, treatment chart review is carried out on a daily basis by clinical pharmacists. The frequency of chart review may be determined depending on the clinical risk of the patient. High-risk patients’ medication charts should be reviewed on a daily basis.

Clinical pharmacists, medical practitioners and nursing staff are competent persons for the treatment chart review. Among them, the clinical pharmacist is the most appropriate person for treatment chart review. Nursing staff are experts to administer medicines; medical practitioners are experts to diagnose the disease. Clinical pharmacists are experts in medicine. Only he can justify the purpose of the treatment chart review.

The Goal of the treatment chart review:

1. Optimization of patient drug therapy,

2. Minimise medication risk and medication error.

Benefits of treatment chart review: Reduced adverse drug events, reduced hospital stay, reduced readmission, reduced medication error and reduced medication cost.

Types of Treatment chart review:

Treatment chart review optimises the quality use of medicines and minimises medicines risk. It is multidisciplinary responsibility to ensure the safe and effective use of medicine. For this purpose, the treatment chart review is divided into three types. Treatment order review, Treatment adherence review and clinical treatment review.

Procedure

A treatment chart review is carried out by the medical practitioners, nursing staff and clinical pharmacists. Following steps are followed for all three types of treatment chart review.

1. Treatment order review (medication order review): It is the simplest review. It can be carried out even in the absence of the patient. It mainly reviews individual medication orders. It checks the safety element of the current medication order. It helps to minimise the medication error. Normally, in a hospital, it is carried out by the registered pharmacist in the hospital pharmacy at the time of dispensing or registered nursing staff at the time of administration of medicines. They check the clarity, validity and appropriateness of the prescription (medication order).

   • Clarity of the prescription includes verification of patients’ six rights of medication administration. These are the right patient, right medications, right dose, right frequency, right route and right indication. Clarity of the prescription includes:

     • Medicine name, route of administration, dose, frequency of administration, duration of administration and indication,

     • Prescribed by generic name or brand name.

     • Use of standard abbreviation, symbol and terminology,

     • Medication orders comply with local, state and central government policy.

   • Validity of the prescription includes checking patient identification, date of prescription i.e. validity of prescription, the signature of the prescriber, fulfilment of the legal requirement, allergy and adverse drug reactions.

   • Appropriateness of the prescription includes checking for allergic conditions, ADR, medication order duplication, medication availability, most appropriate route of administration, most appropriate dosage form, appropriate timing of administration related to food and medication administration, weight/dose appropriateness, checking of blood pressure if required, and checking of drug administration record.

2. Treatment adherence review: It mainly involves checking patients' medicine-taking behaviour and patient opinion about medicines prescribed to them. It also checks the past medication order and patient beliefs about the medicines. The following points are considered during the treatment adherence review. It requires patient involvement. Medical practitioners and clinical pharmacists review treatment adherence. There are two parts to this review.

   • Actual pattern of medicine administration

     • Ask the patient about the consumption of the current medicines,

     • Ask the patients about currently stopped medication,

     • Ask the patients about their medicines consumption behaviour, especially to change the dose without consultation,

     • Is the patient missed the dose during treatment due to any reason?

     • Is the patient face difficulty during medicines administration?

   • Belief about the medicines: Ask the patient

     • are they understand each medicine.

     • are they facing difficulty to administer the medicines?

     • are any side effects of the medicine?

     All these quarries give a fair idea about the intentional or unintentional non-adherence with the recommended treatment. It also helps to gather information related to any barrier that initiates non-adherence such as complicated medication regimen, side effects, misunderstanding related to the purpose of medicines, high cost etc.

     Normally treatment adherence review is carried out at the time of patient admission to the hospital. It is also carried out after the discharge of the patient as a part of follow-up action.

3. Clinical Treatment Review: Clinical pharmacist shall review the treatment chart of all patients admitted to the hospital. Its aim is to address patient conditions with the identification of potential gaps in therapy, appropriate medicines, optimum medicinal effect and minimum medication risk. It must be carried out in the presence of the patient. It is carried out at the time of patient admission, during treatment and at the time of patient discharge. It requires the collection of specific information on patent conditions and medicines use. There may be medication reconciliation after the clinical treatment review. Medication reconciliation is a process to compare all the medications patient is taking.

   • Evaluation of information to guide the treatment.

     • Patient-specific information collection:

       • Allergic conditions and ADR.

       • Medicines used and current medicines prescribed including OTC drugs,

       • Medication pattern taken by the patient including dose route, frequency and formulation,

       • Medicines indications,

       • Medication adherence and storage,

       • Specific clinical data such as laboratory investigation reports, clinical observation progress of treatment,

       • Patient satisfaction and outcomes of treatment,

   • Evaluation

     • Need to continue medication,

     • Missing treatment,

     • Drug interaction and contraindications,

     • Potential adverse drug reactions,

     • Monitoring requirement,

     • Medicines accessibility,

Compiled by: Alok Bains