Identifying discrepancies in electronic medical records through pharmacist medication reconciliation
Autumn L. Stewart, PharmD, BCACP; Kevin J. Lynch, PharmD, BCPS, MBA
J Am Pharm Assoc (2003) 2012;52:59-68. doi:10.1331/JAPhA.2012.10123


Objectives  To describe the types and causes of medication discrepancies in the electronic medical record identified by pharmacist medication reconciliation during outpatient medical visits and to identify patient characteristics associated with the presence of discrepancies.

Design  Observational case series study.

Setting  Indigent primary care clinic in Pittsburgh, PA, from April 2009 to May 2010.

Patients  219 adults presenting for follow-up medical visits and self-reporting medication use.

Intervention  Medication reconciliation as part of patient interview and concurrent chart review.

Main outcome measures  Frequency, types, and reasons for medication discrepancies and demographic variables, patient knowledge, and adherence.

Results  Of 219 patients interviewed, 162 (74%) had at least one discrepancy. The most common type of discrepancy was an incorrect medication documented on the chart. The most common reasons included over-the-counter (OTC) use of medications and patients not reporting use of medications. The presence of one or more medication discrepancies was associated with the use of three or more medications. Patient factors such as gender, age, and race were not associated with discrepancies. Patients able to recall the strength for more than 75% of their medications had fewer discrepancies, while knowledge of the medication name, indication, or regimen had no association with discrepancies.

Conclusion  Pharmacists play a critical role in identifying discrepancies between charted medication lists and self-reported medication use, independent of adherence. Inaccuracies in charted medications are frequent and often are related to use of OTC therapies and lack of communication and documentation during physician office visits. Knowledge of patient-related variables and other reasons for discrepancies may be useful in identifying patients at greatest risk for discrepancies and interventions to prevent and resolve them.

Sign In
APhA Members 
Welcome to JAPhA.org! Please log in below using your APhA username and password. Update your APhA profile.
Not a Subscriber
New to JAPhA? Become an APhA member to receive a full subscription to both the print and online editions.


Register for a FREE limited account to benefit from personalization features such as alerts.


Midelfort L.  Medication reconciliation review. Accessed at www.ihi.org/IHI/Topics/PatientSafety/MedicationSystems/Tools/Medication+Reconciliation+Review.htm, October 20,  2008.
 The Joint Commission. Medication reconciliation National Patient Safety Goal to be reviewed, refined. Accessed at www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/npsg8_review.htm, March 3,  2010.
 Institute of Medicine.  To err is human: building a safer health system.  Washington, DC:  National Academy Press;  2001.
 The Joint Commission.  Accreditation program: ambulatory health care National Patient Safety Goals. Accessed at www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals, June 3,  2010.
Ketchum K, Grass CA, Padwojski A.  Medication reconciliation.  Am J Nurs. 2005;105(11):78–85.[CrossRef][PubMed]
Varkey P, Cunningham J, O'Meara J, et al. Multidisciplinary approach to inpatient medication reconciliation in an academic setting.  Am J Health Syst Pharm. 2007;64:850–4.[CrossRef][PubMed]
Nester TM, Hale LS.  Effectiveness of a pharmacist-acquired medication history in promoting patient safety.  Am J Health Syst Pharm. 2002;59:2221–5.[PubMed]
Gleason KM, Groszek JM, Sullivan C, et al. Reconciliation of discrepancies in medication histories and admission orders of newly hospitalized patients.  Am J Health Syst Pharm. 2004;61:1689–95.[PubMed]
 American Pharmacists Association, National Association of Chain Drug Stores Foundation. Medication therapy management in pharmacy practice: core elements of an MTM service model (version 2.0).  J Am Pharm Assoc. 2008;48:341–53.[CrossRef]
Milone AS, Harris IM, Philbrick AM.  Pharmacist-performed medication reconciliation in an outpatient family medicine clinic.  Presented at the American College of Clinical Pharmacy Annual Meeting, Anaheim, CA,October 18–21,  2009.
Bayoumi I, Howard M, Holbrook AM, et al. Interventions to improve medication reconciliation in primary care.  Ann Pharmacother. 2009;43:1667–75.[CrossRef][PubMed]
Bedell SE, Jabbour S, Goldberg R, et al. Discrepancies in the use of medications.  Arch Intern Med. 2000;160:2129–34.[CrossRef][PubMed]
Peyton L, Ramser K, Harmann G, et al. Evaluation of medication reconciliation in an ambulatory setting before and after pharmacist intervention.  J Am Pharm Assoc. 2010;50:490–5.[CrossRef]
Bassi J, Lau F, Bardal S.  Use of information technology in medication reconciliation: a scoping review.  Ann Pharmacother. 2010;44:885–97.[CrossRef][PubMed]
Johnson CM, Marcy TR, Harrison DL, et al. Medication reconciliation in a community pharmacy setting.  J Am Pharm Assoc. 2010;50:523–6.[CrossRef]
Orrico K.  Sources and types of discrepancies between electronic medical records and actual outpatient medication use.  J Manag Care Pharm. 2008;14:626–31.[PubMed]
Morisky DE, Green LW, Levine DM.  Concurrent and predictive validity of a self-reported measure of medication adherence.  Med Care. 1986;24:67–74.[CrossRef][PubMed]
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).
Please read the other comments before you post yours. Comments are moderated and will appear on the site at the discertion of the editorial staff.
* = Required Field
(if multiple authors, separate names by comma)
Example: John Doe

Related Content

Customize your page view by dragging & repositioning the boxes below.

JAPhA Articles
Topic Collections
PubMed Articles
  • Print
  • PDF Download
  • Email
  • Share
  • Get Citation
  • Submit Comment
  • Article Alerts
    Please Wait... Processing your request... Please Wait.
    You must sign in to sign-up for alerts.

    Please confirm that your email address is correct, so you can successfully receive this alert.

  • Letters To Editor
  • Reprints