practice of Medicine
Medication Safety Toolkit
August 2, 2019
What medications is your patient taking?
Brown bag medication review
The “Brown Bag Review” of medications is a common practice that encourages patients to bring all of their medications and supplements to medical appointments. This provides clinical staff with an opportunity to review and discuss the medications that the patient is taking. Reviewing medications with your patient may help you to:
- Answer the patient’s questions.
- Verify what the patient is taking.
- Identify and/or avoid medication errors and drug interactions.
- Assist the patient to take medications correctly.
To help practices develop a process to improve communication about medications between patients and clinical staff.
We tested the tools in this toolkit with 9 different practices. Practices that tested this tool were shocked at what they found.
“On the day we did the brown bag review, we had a patient experiencing unexplained symptoms. It wasn’t until we looked at his medicine bottles that we realized he was taking a double dose of beta blocker. This explained his symptoms perfectly. Had we not had the medicine bottles to identify the problem, we would have sent him to the hospital.”
“Out of 10-15 brown bag reviews, only 2 were accurate.”
“Out of five brown bag reviews, we found three that had duplicate medicine bottles resulting in double dosing and one discontinued medicine that was still being taken.”
“We found errors in every review, including one where a patient stopped his medicine on his own, another where a patient was taking a supplement the provider did not know about, and others where the medicines did not match what was in the chart.”
1. Get patients to bring in their medicines. Conducting brown bag reviews has been VERY eye-opening for many practices, and most feel it is a worthwhile thing to do. The challenge is getting the patient to bring in their medications. It helps to have a full-scale campaign whereby everyone in the practice is stressing its importance and many different tactics are employed. Here are a few suggestions:
What to bring: Review with patients what to bring.
- All prescription medicines (including pills and creams).
- All over-the-counter medicine they take regularly.
- All vitamins and supplements.
- All herbal medicines.
Ways to remind:
- On the appointment card.
- During the appointment reminder call.
- During the visit: discuss as a part of their visit.
- Hang posters in the exam rooms and the waiting room.
- Bulletin board: Display a bulletin board with anonymous case studies and persuasive reasons for bringing in their medicines.
- Emphasize medication reduction: A brown bag review may result in the physician stopping some medications, which is often appealing to patients.
- Provide a carrier: Consider providing your patients with a small sack (canvas, paper, or plastic) to carry their medications. The sack may have a printed reminder on one side and your practice name on the other.
2. Set out the medications.
- The nurse should place all of the patient’s medications on the counter in the exam room to remind the clinician to perform a medication review.
3. Offer praise to the patient for bringing medications.
- Thank the patient for bringing his or her medications and stress the importance of bringing them to every visit.
4. Review the medications.
- Introduce the review process: Ask the patient if they have any questions about their medications, and acknowledge the purpose of reviewing medications.
- Some helpful questions to ask:
- “Are you taking any new medications since your last visit?”
- “Have you stopped taking any medications since your last visit?”
- “Please show me what you take for your <disease name> ?”
- “How many of these pills do you take each day?”
- “When do you take this pill?”
- “What do you take this medication for?”
5. Clarify medication instructions.
- Clearly review with the patient what medications they should be taking and how to take them. Use the “teach-back method” to confirm understanding.
6. Update the medications in the patient’s chart.
- Clearly document medication inconsistencies and what the patient is directed to take.
- Note in the chart when full medication reviews are done and when partial or updated ones are done to help track the process for the practice.
7. Provide patient with updated list of medications.
- Use consistent and recommended formats to document medications for patients and assist them with remembering and correctly taking them.
Track Your Progress
- Document in the patient medical record whether or not a medication review occurred at the visit. At the end of a day or week, identify the percentage of patients who had a medication review completed.
- During a week, count the number of medication reviews that identified a problem.
The American Medical Association manual “Health Literacy and Patient Safety: Help Patients Understand” offers information on medication reviews.
Reprinted with permission from the North Carolina Network Consortium
DeWalt DA, Callahan LF, Hawk VH, Broucksou KA, Hink A, Rudd R, Brach C. Health Literacy Universal Precautions Toolkit. (Prepared by North Carolina Network Consortium, The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, under Contract No. HHSA290200710014. AHRQ Publication No. 10-0046-EF) Rockville, MD. Agency for Healthcare Research and Quality. April 2010.
Documenting medical administration in the medical record
The administration of prescribed medications by authorized personnel should be conducted in a manner that assures:
1. Right patient
- Check the name on the order and the patient.
- Use 2 identifiers.
- Ask patient to identify himself/herself.
- When available, use technology (for example, bar-code system).
2. Right medication
- Check the medication label.
- Check the order.
3. Right dose Check the order.
- Confirm appropriateness of the dose using a current drug reference.
- If necessary, calculate the dose and have another nurse calculate the dose as well.
4. Right route
- Again, check the order and appropriateness of the route ordered.
- Confirm that the patient can take or receive the medication by the ordered route.
5. Right time
- Check the frequency of the ordered medication.
- Double-check that you are giving the ordered dose at the correct time.
- Confirm when the last dose was given.
6. Right documentation
- Document administration AFTER giving the ordered medication.
- Chart the time, route, and any other specific information as necessary. For example, the site of an injection or any laboratory value or vital sign that needed to be checked before giving the drug.
7. Right reason
- Confirm the rationale for the ordered medication. What is the patient’s history? Why is he/she taking this medication?
- Revisit the reasons for long-term medication use.
8. Right response
- Make sure that the drug led to the desired effect. If an antihypertensive was given, has his/her blood pressure improved? Does the patient verbalize improvement in depression while on an antidepressant?
- Be sure to document your monitoring of the patient and any other nursing interventions that are applicable
These eight factors should be documented in the patient’s office medical record.
Staff should demonstrate competency in the administration and documentation of medications. Competency checks should conducted ongoing basis; the results should be documented in each employee’s personnel file.
Reference: Nursing2012 Drug Handbook. (2012). Lippincott Williams & Wilkins: Philadelphia, Pennsylvania.
Maintaining a medication list in the medical record
Accurate medication records are central to delivering safe, effective clinical care. Drug-drug interactions, drug-disease interactions, incorrect doses, omissions and duplications, are often attributed to out-dated and incomplete medication lists. In emergency situations, medical records may serve as the only source of information on a patient’s medications, thereby performing a critical function in that person’s care.
Furthermore, medication lists represent one of the most important components of an electronic health record (EHR) since they are used for filling refill requests, assessing quality, performing research, and for informing computerized clinical decision support.
Maintaining accurate medication records is a challenge. A multitude of factors such as patients’ lack of knowledge of their medications, physician and nurse workflows, and lack of integration of patient health records across the continuum of care—all contribute to a lack of complete medication reconciliation. In addition, patients change their medications frequently, often visit more than one physician, and may use undocumented over-the-counter medications. Both patient and provider interventions are necessary to facilitate a collaborative approach to medication management.
The process recommended for providers to maintain the most complete and accurate list possible of a patient’s current medications is known as “medication reconciliation”i.
Medication reconciliation is a formal, standardized process that includes the following steps:
- Develop a medication form or format most workable for your group.
- Engage the patient in the process
- Verify- At each patient visit obtain a complete, accurate list of the medications the patient is taking, and compare this list to the list documented in the medical record.
- Ask the patient about medications he/she may be taking from other providers and add these to your list.
- Ask the patient about medications he/she may no longer be taking and delete these from your list.
A comprehensive list of medications should include all prescription medications, herbals, vitamins, nutritional supplements, over-the-counter drugs, vaccines, diagnostic and contrast agents, radioactive medications, parenteral nutrition, blood derivatives, and intravenous solutions (hereafter referred to collectively as medications). Over-the-counter drugs and dietary supplements are not currently considered by many clinicians to be medications, and thus are often not included in the medication record. As interactions can occur between prescribed medication, over-the-counter medications, or dietary supplements, all medications and supplements should be part of a patient’s medication history and included in the reconciliation process, which in turn creates the potential for error.
Commonly overlooked medications include birth control pills, inhalers, eye drops, patches, herbal medicines and medications prescribed by other physicians. As you gather this information, ensure that each drug’s brand name, generic name, strength and frequency are documented with the current date.
- Provide the patient with an updated copy of his/her medication list after performing medication reconciliation at each visit.
- Look for opportunities to provide the patient with additional education about their medications.
With consistent and proper use, a simple medication list can become a very powerful part of the chart providing countless benefits, such as the following:
Efficient charting-- Because the medication list can be updated via a few check marks, it makes documentation quicker and easier. Reviewing it at each visit requires less time than documenting each medication in the progress note. The physician can simply refer to the medication list in the note (“the medication list is reviewed today with the patient”), thus saving time and money in dictation costs.
Safer refills--When patients require prescription refills, the medication list makes it easy to check that the patient is receiving the correct prescription. Physicians and nurses do not have to search through pages of progress notes, as the information is clearly displayed at the front of the chart.
Improved Communication with other physicians--The medication list can easily be photocopied and sent to other doctors involved in the patient’s care so they can see the patient’s medication history. This improved information-sharing between physicians can prevent dangerous medication errors.
Information recall-- A patient’s medication list is often a snapshot of his or her medical history. Reviewing the medication list with the patient helps the physician recall past treatments. This is particularly helpful when a patient presents with a recurring problem.
Allergy documentation-- Ideally, allergies should be documented in one place in the chart. What better place than the medication list? The allergy list should describe the type of reaction and include the date by each allergen.
An effectively maintained medication list through the process of medication reconciliation makes practicing medicine easier, may help facilitate improvements in the quality of patient care, and may also help reduce medication errors. While a perfectly accurate medication list cannot be attributed to a single intervention or tool, a collaborative approach involving education, accountability, and technology can go a long way in helping patients and their providers tackle the challenge of medication safety together.
i The Joint Commission; Medication reconciliation: sentinel event alert. 2006
Record keeping - medication orders, prescriptions and refills
One of the Joint Commission’s National Patient Safety Goals is to “maintain and communicate accurate patient information.”1 Communication errors and issues related to medications are highly associated with adverse events and medical liability claims. According to data from the Physician Insurer’s Association of America, in 2012, medication errors ranked among the top five most prevalent chief medical factors in closed claims.2 Safe medication practices call for accurate record keeping. Safe prescribing is difficult to accomplish without a complete medication record. It is recommended that providers maintain an up-to-date prescription refill list and display it in a prominent or easy-to- find location. When providing refills, document the drug name, strength, frequency, quantity given, and date stopped with initials. Document the reason for discontinuing a certain medication for future reference. Guidance from ECRI (2013) states:
'Maintaining the accuracy of medical records regarding each patient’s medication regimen has become the focus of intense efforts across the continuum of care to ensure that the drugs the patient is taking are reviewed at all transitions in care—a process known as medication reconciliation. The purpose is to avoid errors of omission, duplication of therapy, and drug-drug and drug-disease interactions.' 3
In office-based settings where there is more than one physician or provider, errors can occur when important information is not documented or not readily available in the medical record. It is important that medication information be documented in a consistent location and in a manner that is understood by all providers involved in the care of the patient. Communicating about the medication list, making sure it is accurate, and reconciling any discrepancies whenever new medications are ordered or current medications are adjusted, are essential to reducing the risk of transition-related adverse drug events.
1 The Joint Commission. National Patient Safety Goal 3.06.01- Maintain and Communicate Accurate Patient Medication Information. Chicago, IL: The Joint Commission.
2 Physician Insurers Association of America. Risk management review: 2013 edition, combined specialties, January 1, 2003 - December 31, 2012. Rockville , MD: Physician Insurers Association of America, 2013.
3 ECRI Institute. " Managing Risks in the Physician's Practice: Supplement A: Outpatient Settings 2." Healthcare Risk Control Analysis, September 2013.
Reconciling records – cases and commentaries
Reprinted with permission of AHRQ WebM&M Commentary by Hardeep Singh, MD, MPH; Dean F. Sittig, PhD; Maureen Layden, MD, MPH The Cases
Case 1. A patient receiving care at a Veterans Affairs (VA) outpatient clinic was admitted to a local teaching hospital. When discharged, he was instructed to "resume" taking torsemide, although he had never taken this powerful diuretic previously. In his first follow-up appointment with his usual physician at the VA outpatient clinic, he requested a refill of the torsemide. His medication record showed that he had been taking terazosin for benign prostatic hyperplasia prior to the hospitalization; there was no record of his being on torsemide. When questioned about it, the patient said he had told the emergency department (ED) staff that he was taking a medicine whose name started with the letter T to make him urinate. The ED staff had entered torsemide into the electronic medical record. When discharged, this came up as an at-home medication, and he was instructed to resume taking it. When he came to see his primary MD at the VA clinic requesting a medication he didn't need and hadn't taken before, the error was detected.
Case 2. At another local teaching hospital, a family had given incorrect data to the ED staff (including listing the patient as being on prednisolone rather than prednisone), and the physicians caring for the patient had simply checked off the option to continue the home medications. When the records were carefully reviewed by a physician consulting for an upcoming cardiac procedure, almost all of the medications were found to be incorrect. Had the cardiologist assumed that the other physicians and nurses had accurately entered the medications, the errors would have gone undetected, and the patient's chronic steroid dependence might have not been appropriately addressed perioperatively. Fortunately, no harm occurred.
The Commentary by Hardeep Singh, MD, MPH; Dean F. Sittig, PhD; Maureen Layden, MD, MPH Both cases illustrate medication errors related to inaccurate patient medication information. Lookalike, sound-alike medication errors (1) might be prevented by effective medication reconciliation, a process emphasized by the Joint Commission National Patient Safety Goals.(2) However, institutions continue to struggle with developing and implementing safe and reliable reconciliation processes.(3) Furthermore, documentation and perpetuation of incorrect information in electronic health records (EHRs) does not pertain only to medications. Features specific to electronic data such as autocompletion during data entry (4), copying and pasting, and use of templates that automatically import information can create significant safety issues when data is incorrect. In this commentary, we use medication reconciliation as an example to discuss several "defenses" that might mitigate errors in reconciliation of medical records.
Defense 1: EHR Interoperability In both cases, had the inpatient and outpatient EHRs been able to "talk with" one another (system interoperability), errors might have been prevented. Technical and organizational challenges associated with achieving interoperability (both within and external to the institution) are currently being discussed in many national forums.(5)
Defense 2: Standardized Reconciliation Procedures and Practices It is unclear whether the non-VA facilities were using any medication reconciliation procedures, which might have prevented errors by the ED and discharge team in Case 1 and the inpatient team in Case 2. To be effective, reconciliation procedures first need to be better defined and standardized. (6) For instance, based on The Joint Commission and the VA Medication Reconciliation Initiative, effective medication reconciliation involves the following tasks:
- Obtain current medication information (e.g., all medications the patient is taking, how medications are being taken, and any associated problems or adverse reactions) from patient, caregiver, and family or other relevant sources. This may be obtained by brown bag inventory, verbal history, or medication lists.
- Compare that with medication information available from the EHR or other sources such as pharmacy data, other providers, and health care institutions.
- Reconcile, amend, or update these medications along with any changes pertinent to the episode of care into one medication list that is then documented.
- Communicate this medication information to the appropriate members of the health care team (within or outside the health care institution) as well as the patient, caregiver, and family.
- Explain the importance of maintaining accurate and up-to-date medication information to the patient, caregiver, and family.
A similar approach may also be useful for reconciling other types of critical information in the EHR. Emerging evidence suggests that problem lists are often outdated and incorrect, and with extensive copying and pasting of electronic notes, information that might have been critical at one point in time may no longer be accurate or relevant.(7) Defense 3: Appropriate Use of Both Simple and Advanced Technology
Information technology (IT)–based techniques might prevent, as well as identify, reconciliation errors. For example, several techniques are currently being used or tested to guide medication reconciliation in EHR systems.(8) These techniques mostly facilitate the process of obtaining medication information.(9) However, if medication information is erroneously documented in the first place, this misinformation can be easily perpetuated in the EHR in the absence of other defenses designed to detect such errors. One promising solution is a user-friendly kiosk that patients can use to reconcile medications before seeing their providers.(10) This kiosk interfaces with the EHR and is being evaluated at the Portland VA facility. A "Virtual Patient Coach" is another emerging technology that could potentially perform these tasks (http://www.bu.edu/fammed/projectred/meetlouise.html). Such technologies can minimize providers' cognitive burden and help measure the effectiveness of reconciliation processes (e.g., by calculating discrepancy rates).
Future EHR-based software functionalities might be able to compare two sources of information and automatically identify, track, and alert users to discrepancies.(11) Some current EHRs can highlight copied information, and some prevent injudicious use of copying and pasting. Although advanced IT might be able to streamline reconciliation, judicious use of verbal communication remains essential. When in doubt, such as in Case 1, a verbal dialogue should be initiated with the "remote" provider.
Defense 4: A New Attitude and Culture With EHRs, we can finally find the information that we are looking for. However, an unintended consequence includes the potential for outdated, unverified, or even inaccurate data to be transferred indefinitely. At transitions, providers must double-check medication information from patients, family members, caregivers, and other health care team members from their own or external institutions. Future medical homes (12) might be the place to obtain this information easily. Examining medication bottles ("brown bag review") and asking concrete questions, such as "tell me about all the medications you have taken in the last 24 hours," help elicit more accurate medication information from patients. Providers must also not hesitate to contact the dispensing pharmacies and use other tools such as online e-prescribing clearinghouses.(13)
A greater challenge is to inculcate a culture of "dynamic skepticism," an attitude of questioning the validity of previous assumptions by constantly evaluating incoming data.(14) This concept from aviation may be beneficial in certain health care situations and might have led the cardiologist in Case 2 to find the error. Providers must resist the automatic assumption that previously obtained information is (still) accurate, especially when it does not make sense. For instance, the ED provider in Case 1 could have asked, "Is there a reason for this patient to be taking torsemide?"
Defense 5: Patients, Our Final Defense An engaged patient is one of our best strategies to prevent reconciliation errors. However, as illustrated by Case 2, both patients and their caregivers and family members must keep critical information up to date and remain engaged with providers across different systems. Web-based patient portals, such as "My HealtheVet" (http://www.myhealth.va.gov/), allow patients to compare their information with that of the organization to help address any discrepancies they identify. Patients themselves can also communicate significant updates or changes via web-based secure messaging (15) or other available means. And finally, patients and caregivers must also continuously monitor and develop a healthy amount of skepticism for risky situations (such as medications at transitions).
Take-Home Points Errors in reconciling medication records can be prevented by using a multifaceted approach that includes:
- Better EHR linkages.
- Standardized practices and procedures for certain high-risk tasks such as medication reconciliation.
- Using technology to reduce (and not introduce) errors that might get perpetuated.
- Developing new attitudes such as dynamic skepticism.
- Engaging patients in actively contributing to their care and monitoring their clinical conditions.
Hardeep Singh, MD, MPH Assistant Professor of Medicine Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine Dean F. Sittig, PhD Professor of Health Information Sciences University of Texas School of Biomedical Informatics Maureen Layden, MD, MPH Director, VA Medication Reconciliation Initiative
Veterans Health Administration, Pharmacy Benefits Management 1. American Hospital Association, American Society of Health-System Pharmacists, Hospitals and Health Networks. Medication safety issue brief. Look-alike, sound-alike drugs. Hosp Health Netw. 2005;79:57-58. [go to PubMed] 2. The Joint Commission. 2010 National Patient Safety Goals. Oakbrook Terrace, IL: The Joint Commission; 2010. [Available at] 3. Bails D, Clayton K, Roy K, Cantor MN. Implementing online medication reconciliation at a large academic medical center. Jt Comm J Qual Patient Saf. 2008;34:499-508. [go to PubMed] 4. Côté RG, Jones P, Apweiler R, Hermjakob H. The Ontology Lookup Service, a lightweight crossplatform tool for controlled vocabulary queries. BMC Bioinformatics. 2006;7:97. [go to PubMed] 5. Blumenthal D. Stimulating the adoption of health information technology. N Engl J Med. 2009;360:1477-1479. [go to PubMed] 6. Rogers G, Alper E, Brunelle D, et al. Reconciling medications at admission: safe practice recommendations and implementation strategies. Jt Comm J Qual Patient Saf. 2006;32:37-50. [go to PubMed] 7. Hartzband P, Groopman J. Off the record—avoiding the pitfalls of going electronic. N Engl J Med. 2008;358:1656-1658. [go to PubMed] 8. Bassi J, Lau F, Bardal S. Use of information technology in medication reconciliation: a scoping review. Ann Pharmacother. 2010;44:885-897. [go to PubMed] 9. Schnipper JL, Hamann C, Ndumele CD, et al. Effect of an electronic medication reconciliation application and process redesign on potential adverse drug events: a cluster-randomized trial. Arch Intern Med. 2009;169:771-780. [go to PubMed] 10. Lesselroth B, Adams S, Felder R, et al. Using consumer-based kiosk technology to improve and standardize medication reconciliation in a specialty care setting. Jt Comm J Qual Patient Saf. 2009;35:264-270. [go to PubMed] 11. Hasan S, Duncan GT, Neill DB, Padman R. Towards a collaborative filtering approach to medication reconciliation. AMIA Annu Symp Proc. 2008;288-292. [go to PubMed] 12. Nutting PA, Miller WL, Crabtree BF, Jaen CR, Stewart EE, Stange KC. Initial lessons from the first national demonstration project on practice transformation to a patient-centered medical home. Ann Fam Med. 2009;7:254-260. [go to PubMed] 13. Singh H, Thomas EJ, Sittig DF, et al. Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain? Am J Med. 2010;123:238-244. [go to PubMed] 14. Dunn EJ, Mills PD, Neily J, Crittenden MD, Carmack AL, Bagian JP. Medical team training: applying crew resource management in the Veterans Health Administration. Jt Comm J Qual Patient Saf. 2007;33:317-325. [go to PubMed] 15. Nazi KM, Woods SS. MyHealtheVet PHR: a description of users and patient portal use. AMIA
Reprinted with permission of AHRQ WebM&M. Singh H, Sittig DF, Layden M. Reconciling records. AHRQ WebM&M [serial online]. November 2010. Available at: http://webmm.ahrq.gov/case.aspx?caseID=229.
The teach-back method
Reprinted with permission from the North Carolina Network Consortium
Overview Studies have shown that 40-80 percent of the medical information patients receive is forgotten immediatelyi and nearly half of the information retained is incorrect.ii One of the easiest ways to close the gap of communication between clinician and patient is to employ the “teach-back” method, also known as the “show-me “method or “closing the loop.”iii Teach-back is a way to confirm that you have explained to the patient what they need to know in a manner that the patient understands. Patient understanding is confirmed when they explain it back to you. It can also help the clinic staff members identify explanations and communication strategies that are most commonly understood by patients.
Purpose To provide your practice with examples and helpful advice on performing the teach-back method.
Action Learn the teach-back method. The North Carolina Program on Health Literacy offers a collection of presentations and training videos on the website.
Testimonial “I decided to do teach-back on five patients. With one mother and her child, I concluded the visit by saying ‘So tell me what you are going to do when you get home.’ The mother just looked at me without a reply. She could not tell me what instructions I had just given her. I explained the instructions again and then she was able to teach them back to me. The most amazing thing about this “ah ha” moment was that I had no idea she did not understand until I asked her to teach it back to me. I was so wrapped up in delivering the message that I did not realize that it wasn’t being received.” Keep in mind:
- This is not a test of the patient's knowledge: This is a test of how well you explained the concept.
- Use with everyone: Use teach-back when you think the person understands and when you think someone is struggling with your directions.
- Teach to all staff: All members of the practice staff can use it to make sure their communication is clear.
Suggested Approaches When Using Teach-back.
- “I want to be sure that I explained your medication correctly. Can you tell me how you are going to take this medicine?”
- “We covered a lot today about your diabetes, and I want to make sure that I explained things clearly. So let’s review what we discussed. What are three strategies that will help you control your diabetes?”
- “What are you going to do when you get home?”
Try the teach-back method
- Start Slowly. Initially, you may want to try it with the last patient of the day.
- Plan your approach. Think about how you will ask your patient to teach-back information based on the topic you are reviewing. Keep in mind that some situations will not be appropriate for using the teach-back method.
- Use handouts. Reviewing written materials to reinforce the teaching points can be very helpful for patient understanding.
- Clarify. If patients cannot remember or accurately repeat what you asked them, clarify your information or directions and allow them to teach it back again. Do this until the patient is able to correctly describe in their own words what they are going to do, without parroting back what you said.
- Practice. It may take some getting used to, but studies show that once established as part of a routine, it does not take longer to perform.
Reprinted with permission from the North Carolina Network Consortium
DeWalt DA, Callahan LF, Hawk VH, Broucksou KA, Hink A, Rudd R, Brach C. Health Literacy Universal Precautions Toolkit. (Prepared by North Carolina Network Consortium, The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, under Contract No. HHSA290200710014. AHRQ Publication No. 10-0046-EF) Rockville, MD. Agency for Healthcare Research and Quality. April 2010 http://www.nchealthliteracy.org/teachingaids.html
References i Kessels RP. Patients' memory for medical information. J R Soc Med. May 2003;96(5):219-22. ii Anderson JL, Dodman S, Kopelman M, Fleming A. Patient information recall in a rheumatology clinic. Rheumatology. 1979;18(1):18-22. iiiSchillinger D, Piette J, Grumbach K, et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003;163(1):83-90.
The information provided in this resource does not constitute legal, medical or any other professional advice, nor does it establish a standard of care. This resource has been created as an aid to you in your practice. The ultimate decision on how to use the information provided rests solely with you, the PolicyOwner.