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CPT TODD A. REEDER, PHARM.D., RN, is Chief of Inpatient Pharmacy, Brooke Army Medical Center, San Antonio, TX; at the time of writing he was Pharmacy Resident, University of Virginia Medical Center (UVAMC), Charlottesville. ALAN MUTNICK, PHARM.D., FASHP, is Director of Clinical Effectiveness, Mercy Health Partners, Southwest Ohio, Cincinnati; at the time of writing he was Assistant Director of Clinical Practice and Program Director, Pharmacy Practice Residency, Pharmacy, UVAMC.

Address correspondence to CPT Reeder at Brooke Army Medical Center, 3851 Roger Brooke Drive, San Antonio, TX 78234 (todd.reeder{at}amedd.army.mil).

Purpose. Physician-obtained medication histories were compared to those obtained by a pharmacist. Methods. Patients whose medication histories were obtained were included in the evaluation if they were at least 18 years old and admitted to an internal medicine service at the University of Virginia Medical Center. Data were collected in two phases. The first 20 patients identified for inclusion were asked to provide an accurate medication history to pilot test the medication history form used by the pharmacist and received no pharmacist follow-up or interventions. In the second phase, patients were asked to provide an accurate medication history, and a pharmacist intervened when discrepancies in the pharmacist-obtained medication history were identified. Results. A total of 55 patients were included in the study. The pharmacists identified 614 medications for these patients, compared with 556 identified by the physicians (p 0.001). The pharmacist documented significantly more medication doses and dosage schedules than did physicians (614 versus 446 and 614 versus 404, respectively) (p 0.001 for both comparisons). The pharmacist identified 353 discrepancies, including 58 medications not initially identified from the physician-obtained histories. The pharmacist intervened for 161 discrepancies, correcting 142 after contacting the respective physician; 19 medication discrepancies could not be justified by the physician. Conclusion. A total of 353 discrepancies were identified when medication histories obtained by physicians were compared with those obtained by a pharmacist during the study. During the intervention phase, the majority of discrepancies identified were either corrected by the pharmacist after contacting the respective physician or justified by the physician. Index terms: Documentation; Interventions; Patient information; Pharmacists; Physicians