Medication Counseling: Analysis of Electronic Documentation Using the Clinical Care Classification System

Medication counseling is a central aspect of medication safety. Counseling refers to the process of informing, advising and administering medication to help patients manage their medication regimen. This pilot study examined 379 descriptions of medication counseling carried out in surgical care and documented in an electronic patient record system by using the Clinical Care Classification System. The objective was to identify counseling methods and to evaluate the need for additional counseling descriptor codes in the record. Eleven counseling methods were identified and the data were classified according to counseling methods with and without documentation of the nature of the interaction with patients. There were no descriptions of the nature of counseling conducted in 127 of the documented entries. These results can be used when developing the documentation of medication care in electronic patient records.