Table 2.
The six annotations types that were observed, including the number of each type observed and the percent of all annotations. Examples are taken from actual medication lists. Latin abbreviations are defined in brackets.
| Annotation Type, Number Observed (%) | Definition | Examples | ||
|---|---|---|---|---|
| Historical, 44 (28%) | Indication, previous treatments, prescriber, start and stop dates | fluconazole 100 mg daily (for thrush, beginning mid September - thrush went away within 1.5 weeks) | Wellbutrin (started 2 days ago) | neurontin 300mg tid [three times daily] (by Pain clinic) |
| Reconciliation, 35 (22%) | Instructions regarding medication changes | Glucotrol 5mg PO [by mouth] daily (NEW) | Lasix 40mng Po [by mouth] daily (increased) | - HOLD Metformin 850 mg PO daily |
| Adherence, 28 (18%) | Differences between prescription and how the patient takes the medication | Glipizide 20 mg bid [twice daily] (pt reports only taking 10 mg daily) | fibercon 625 bid [twice daily] (pt does not take every day, states minimal effectiveness) | -lasix 40 daily (pt taking lasix 80 mg bid [twice daily]) |
| Medication Information, 24 (15%) | Drug class or generic name | Sitaglipitin 50mg (Januvia) po [by mouth] daily | Anama (some OTC herbal med) | Prograf (Tacrolimus) 2mg at 10am and 10pm |
| Source, 16 (10%) | Where did the medication list come from | pt brought pill bottles 8/31 | (patient does not know her medications, lists provided below per d/c summary 9/08) | (pt brought in list from PMD) |
| Certainty, 13 (8%) | How certain is the clinician that the medication list is accurate | Hydroxyzine 25 mg po [by mouth] ? Frequency | (pt does not know doses, family to bring meds in am) | Norvasc 5 mg po daily (may be 10 patient unsure.) |