Background: The hospital discharge process is challenging and opportune for human error. Medication discrepancies continue to be a patient-safety problem, exacerbated with the multiple sources of discharge medication documentation. Medication discrepancies may lead to medication errors and may contribute to adverse drug events with potential subsequent healthcare utilization and cost. Discharge medications can be listed [...]

Background: While the electronic health record (EHR) provides many benefits, its use can easily allow for incomplete documentation of relevant historical information. The EHR is designed to store documentation of a patient’s past medical history (PMH), surgical history (PSH), family history (FH), and active hospital problems in the History tab. When the information is in [...]