5PSQ-037 Evaluation of the completeness of patients’ medication reports and discharge summaries at discharge from two wards using complete medication documentation at discharge measure (CMDD-M)

<h3>Background and Importance</h3> In Sweden, hospital discharge documentation must include a discharge letter directed to the patient containing a medication report, detailing changes made during the hospital stay. Incomplete documentation of medication changes has been correlated to medication errors leading to hospital readmissions. Given this correlation, it is important to assess the quality and completeness of medication documentation within the Swedish healthcare system. <h3>Aim and Objectives</h3> This study aimed to evaluate the quality and completeness of discharge documentation using the checklist CMDD-M as part of ongoing quality improvement initiatives at geriatric- and internal medicine wards. <h3>Material and Methods</h3> A retrospective cross-sectional study was conducted reviewing electronic medical records from two wards. Patients included were those admitted in October 2021, aged 50 or older, with at least one lasting medication change during their hospital stay. CMDD-M was used to assess the completeness of discharge documentation. To achieve a maximum score of 7 points all medication changes must be mentioned including reasoning and follow-up plan. <h3>Results</h3> A total of 80 patient journals were reviewed using CMDD-M where 19 (23.8%) patient journals scored 7 points, and the average was 4.6. For eight (10%) patients the medication report was missing completely. The most frequently missed criterion was the omission of one or more relevant medication changes, 48 (60%), followed by reason for change not noted, 22 (27.5%). There was a non-statistical correlation between number of medication changes and the completeness of documentation. <h3>Conclusion and Relevance</h3> In summary, the majority of the reviewed discharge documentation received a low score, and therefore did not meet the Swedish legal requirement. Similar findings have been reported in studies abroad. The findings in this study highlights a need for quality improvements in discharge documentation. CMDD-M may function as a comprehensive, quick, and easy-to-use tool for caregivers. Additionally, it could be used as an outcome measure in research studies aiming to enhance discharge procedures. <h3>References and/or Acknowledgements</h3> <h3>Conflict of Interest</h3> No conflict of interest