Download Task A The Importance of Medicines History Taking

School of Medicines
Optimisation & Pharmacy
Nationally Recognised Competency
Framework for Pharmacy Technicians: The
Assessment of Medicines Management Skills
Medicines History Taking: Training Module
Website: https://medslearning.wordpress.com/
Contact: Administration Team
Inpatients Pharmacy, Floor B
Leeds General Infirmary
Great George Street, Leeds LS1 3EX
T: 0113 392 3288
E: [email protected]
Document Reference Number: PDU/AMMTS/001
Review Date: April 2018
Version: 3.0 April 2016
Supersedes: versions 2.0 and 2.1
This work book is also Module 3 of Nationally Recognised Competency Framework for
Pharmacy Technicians: Assessment of Medicines Management Skills
Medicines Reconciliation (Level 1) Medicines History Taking
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This document has been produced by the School of Medicines Optimisation and Pharmacy
to assist in the training and development in Medicines History Taking.
This module consists of:
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
Medicines History Taking Training Module (this workbook)
Assessment Workbook for Medicines History Taking
Using this workbook, ALL candidates are required to:
 Complete a number of tasks and discuss with a mentor1 to test knowledge and
understanding after reading sections of the workbook. Task A to G
 Candidates are required to complete at least four mock medication histories as part
of a local assessment. See task H
 Reading: Complete the reading listed. Tasks I to K
 Documented discussions: Complete the list of discussions. Tasks L to S
 Local Assessment observations:
o Two direct observations should be used to assess your communications skills:
talking to a patient and phoning a GP surgery (using checklists provided).
o Sources of Information assessment - A checklist will be used to follow training on
the use of sources of information.
This module can be used as standalone training covering the specific area of work for the
training of pharmacy staff involved in medicines management roles. It is also module 3 in the
National Accreditation of Medicines Management skills for Pharmacy Technicians:
Medicines Reconciliation Level 1 Medicines History Taking
This module workbook should be read in conjunction with the candidates own Trusts
Medicine Code, policies and procedures.
It is recommended that training and assessment methods and assessment criteria for this
module are followed even when not studying for national accreditation. They have been
developed to provide a structured approach to training and assessment across the region.
The associated documentation has been developed to support training and assessment
activities for this module.
Candidates must have a nominated learning mentor* to support them through this module.
The information contained in this booklet provides a variety of training and assessment
methods, which may be adapted to address the content and depth of training required in
each trust.
A candidate skills evaluation form must be completed to assess skills before and after
training and retained in the candidates portfolio (see appendix A).
When studying for National Accreditation the scheme handbook must also be used.
All other information and documentation required for assessment purposes is
available in the Scheme Handbook and online via https://medslearning.wordpress.com/
During your training you will be required to:
1
The mentor will be a person who has been approved to mentor candidates completing this scheme
(See scheme handbook appendix a, for more information on mentor training and competencies).
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Build a portfolio of evidence (to Y&H Standards of Work)
Be familiar with and have a working knowledge of procedures and policies relevant to
your training.
Demonstrate learning and application of knowledge
Complete tasks and activities
Have regular reviews with mentor
Undertake a variety of assessments
Yorkshire and Humber Standards of Work
These are a set of standards developed for the region and mapped to National Occupational
Standards (NOS) performance and knowledge. In this case SFHPHARM29 Take a
medication history.
The training section of this module (including the tasks) have been mapped to this standard
and the contents of the candidates portfolio must reflect the knowledge and understanding
requirements of the standards.
It is the responsibility of the candidate and the mentor to ensure the areas of knowledge and
understanding are covered during training and evidence is contained in the portfolio for
review.
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Table of Contents
Table of Contents.................................................................................................................. 4
Introduction ........................................................................................................................... 6
Medicines History Taking ...................................................................................................... 7
What is a medication history?............................................................................................ 7
Whose responsibility is it? ................................................................................................. 7
Communication skills ............................................................................................................ 8
Talking to patients ............................................................................................................. 8
Communicating with other members of the healthcare team ............................................. 8
Communication using the telephone (GP surgery) ............................................................ 8
Communicating with other members of the pharmacy team .............................................. 9
Sources of information used in obtaining a medication history ............................................ 10
Thinking Clinically ............................................................................................................... 14
What is the reason for admission? .................................................................................. 14
Past Medical History (PMH). ........................................................................................... 14
Medication....................................................................................................................... 14
Patient Circumstances .................................................................................................... 14
High Risk Medications......................................................................................................... 16
Warfarin .......................................................................................................................... 16
Insulin ............................................................................................................................. 16
Chemotherapy ................................................................................................................ 16
Methotrexate ................................................................................................................... 17
Substance misuse (methadone and buprenorphine for addiction) ................................... 17
Opioids ............................................................................................................................ 18
Anti-epileptic medications................................................................................................ 18
Other medication to take particular care with ................................................................... 18
Parkinson’s medication ............................................................................................... 18
Other once weekly medications ................................................................................... 18
Steroids ....................................................................................................................... 18
Depot injections ........................................................................................................... 18
Patches ....................................................................................................................... 19
Allergy Status ...................................................................................................................... 20
Over The Counter medicines and herbal remedies ............................................................. 21
Documentation and Follow Up ............................................................................................ 22
Medication History Documentation .................................................................................. 22
Documentation of Omissions or Discrepancies ............................................................... 22
Out of hours .................................................................................................................... 23
Incidents that could cause harm and near misses. .......................................................... 23
Checklist for taking a medication history ............................................................................. 24
Practical Activities ............................................................................................................... 25
Task A The Importance of Medicines History Taking ....................................................... 26
Task B Advantages and Disadvantages of Sources ........................................................ 28
Task C Examples of organisational documentation ......................................................... 29
Task D Read your local Medication Safety Alerts ............................................................ 30
Task E Medication with similar names and different formulations .................................... 31
Task F Problem Solving .................................................................................................. 32
Task G Communication Scenarios .................................................................................. 34
Task H Example Medication Histories to Complete ......................................................... 36
Task I Essential Reading Medicines Reconciliation - Procedures and Policies ............... 37
Task J Essential Reading Medicines Reconciliation - Procedures and Policies ............... 38
Task K Medicines Management Essential Activities ........................................................ 39
Documented discussions with mentor ................................................................................. 40
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Task L Explain the terms: Medication History, Medicines Reconciliation and Medicines
Review ............................................................................................................................ 41
Task M Discuss overview of the process for medication history taking ............................ 42
Task N Explain what to do with omissions or discrepancies in medication histories and
how you would communicate these to the appropriate people......................................... 43
Task O Discuss what to do when obtaining a medication history during out of hours ...... 44
Task P Discuss how to record near misses resulting from medication histories .............. 45
Task Q Explain your department’s procedure on incident reporting ................................. 46
Task R Discuss your understanding of all listed high risk medication and the most
appropriate information source to use for each ............................................................... 47
Task S Research and then discuss the following with your mentor ................................. 48
Local Assessment Observations ......................................................................................... 49
Medication history sources - observation checklist .......................................................... 49
Talking to a patient - observation checklist ...................................................................... 50
Talking to a GP surgery - observation checklist ............................................................... 51
Appendix A Candidate Evaluation of Learning – Medicines History Taking ......................... 52
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Introduction
The NPSA defined medicine reconciliation as encompassing:
Collection
Checking
Communicating
Collection: taking a medication history.
Checking: the medication history is checked against the drug chart in conjunction with the
medical record. This may not always match as there may have been intentional changes
made to the patient’s medication.
Communicating: includes documenting the medication history and any changes made to
the medication. By recording this information anyone involved in the patient’s care in the
future can clearly see what changes have been made.
It is important that you recognise the differences between medicine reconciliation, medicines
history taking and medicine review.
Medicines Reconciliation
The aim of medicines reconciliation on hospital admission is to ensure that medicines
prescribed on admission correspond to those that the patient was taking before admission.
Details to be recorded include the name of the medicine(s), dosage, frequency, and route of
administration. Establishing these details may involve discussion with the patient and/or
carers and the use of records from primary care. It does not include medicines review. 2
Medicines History taking is the process undertaken to ensure a correct detailed list of each
prescribed and non prescribed medication the patient takes on admission to hospital and
their allergy status is clearly documented in the medical record.
Medicine Review is separate to the medicines reconciliation process. This process can
only be undertaken by a pharmacist. The pharmacist assesses the whole prescription to
assess that the medication prescribed is appropriate for that patient. There are 3 levels of
medicine review.
This training module focuses on medicines history taking. However, as it is hard to
distinguish between medicines history taking and the initial stages of medicine reconciliation,
some of your role in taking a medication history will also involve the ‘checking’ and
‘communication’ parts of the medicine reconciliation process.
2
http://guidance.nice.org.uk/PSG001
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Medicines History Taking
Establishing an accurate medication history for patients admitted to hospital is important
since this will form the basis on which future inpatient therapeutic decisions are made. The
medication history process can also be used to identify any patient related medicines
management issues that may have affected the admission or that may affect discharge.
What is a medication history?
A detailed list of every prescribed and non-prescribed medication a patient is taking on
admission to hospital. This includes any recent changes to medication and any recent acute
prescriptions e.g. antibiotics, allergy status.
The process in brief
 Confirm patient’s details. e.g. name, DOB etc
 Aim to obtain information from a minimum of two sources.
 Consider the medical condition and the reason for admission.
 For each prescribed and non-prescribed medication document clearly and legibly.
o Drug name and formulation (e.g. inhaler type, whether product is modified release
preparation)
o Strength/dosage regimen
o Duration of treatment (where appropriate)
o Beneficial or adverse effects (if any)
o Reasons for discontinuation (if any)
 Document the medication history on the Medication History form or in the clerking or
continuation section of the medical records (if the medication history is written there
already) and clearly state the sources used to obtain the medication history.
 Sign and date the entry, including your professional status and a contact number.
 Document if the patient does not comply with the prescribing instructions of any of their
medication.
 Confirm the allergy status.
 File any paper sources used to obtain the medication history in the patients medical
record.
 Document any problems the patient has with their medication, including compliance, and
refer appropriately.
Whose responsibility is it?
Doctors, pre-assessment practitioners, pharmacists, pre-registration pharmacists and
pharmacy technicians all have a responsibility in taking an accurate medicines history.
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Doctors are responsible for documenting a medication history and prescribing as
appropriate for the patient.
Nurses trained in taking medication histories are responsible for documenting a
comprehensive medication history and should highlight any issues to the prescriber
or pharmacy staff.
Pharmacists are responsible for documenting a comprehensive medication history
and undertaking medicines reconciliation as defined by Medication History SOP and
Reconciliation of Medicines SOP.
Pharmacy technicians and pre-registration pharmacists are responsible for
documenting a comprehensive medicines history and communicating any
discrepancies to the Pharmacist as defined by Medication History SOP.
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Communication skills
Good verbal and written communication skills are essential whilst working within clinical
areas.
It is important that you create an environment suitable for open and confidential discussion
with the patient or their carer before asking about their medication.
You are required to demonstrate your ability to communicate well in the following areas:
 Talking to patients
 Communicating with members of the healthcare team on the ward
 Using the telephone e.g. to contact a GP surgery
 Communicating with other members of your pharmacy team
 Writing in the medical record
Talking to patients
Always make sure you explain who you are when talking to a patient. During their admission
to hospital they may have to talk to many different healthcare professionals (nurses, doctors,
physiotherapists and pharmacy to name a few). This can leave them feeling confused as
often similar questions will be asked by all these different people. Explaining who you are
and why you are asking the questions you are, will make a patient more likely to co-operate
with you and give you the answers you need to complete a medication history.
Communicating with other members of the healthcare team
When on a ward always introduce yourself and make sure other members of the healthcare
team know who you are and why you are there. Many different healthcare professionals
attend wards on a daily basis to deliver patient care. If you are not a regular member of staff
on the ward and they do not know who you are, you may be challenged at some point as to
the purpose of your visit.
Communication using the telephone (GP surgery)
As part of compiling a medication history it is often necessary to contact a GP surgery to
gain information. You do not usually need to speak directly with the GP. Obtaining the
information from a receptionist with access to prescription records is acceptable in the
majority of cases. You need to remember however, that this person is often not medically
trained and will only be reading a list. If possible ask for a confirmation fax or, if appropriate,
ask to speak to the GP for clarification.
Prior to asking for information over the phone you should have the following information to
hand:
 Patient name
 GP name and telephone number
 Date of birth
 NHS number
 Patient’s address
 Ward fax number
When making the phone call you should remember the following:

Be polite

Always say who you are, where you are calling from and why you are calling

Make sure you are speaking to the relevant person
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Make sure you have the correct information about a patient to hand as the
receptionist will ask for at least one patient identifier.
For each repeat and current medication confirm:
o Drug name and formulation (e.g. inhaler type, whether product is modified
release).
o Strength/dosage regimen (write micrograms, units and other abbreviations in
full).
o Duration of treatment
o Date of last issue
o Adverse effects (if any)
o Reasons for discontinuation (if any)
o Quantity used (if it is a 7 day prescription the patient may have a compliance
aid. If so, confirm community pharmacy contact details).
Check for any recent acute prescriptions (in the last 1-2 months), confirm the drug details as
per repeat and current medication above.
 Check allergy status
o What are the agents?
o What was the reaction?
o When was it recorded?
 Ask for a fax to confirm the information you have received. Make sure you know your
fax number before you ring.
 When asking for a fax always confirm that they are going to send information
regarding repeat prescriptions, acute prescriptions and allergy status.
Communicating with other members of the pharmacy team
Each ward in the hospital has a different relationship with their pharmacy team. The ward
pharmacist and technician must discuss how things usually work within the area they are
working and should agree on the best way to communicate to each other. This will differ
from ward to ward although many use handover sheets of some form
It should also be discussed what the technician should do when the pharmacist has left the
ward for the day and they have discovered a discrepancy after completing medicines
reconciliation.
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Sources of information used in obtaining a medication
history
There are many information sources available to collect an accurate medication history.
What follows is an extensive, although not exhaustive, list of commonly used sources for
medication histories.
Remember:
 The best person to tell you what medication the patient takes, is the patient
themselves - provided they are not confused.
 The most accurate medication histories tend to be formulated when two or more
different sources are used so that the information can be pieced together and
confirmed with the patient.
 The current medical record should always be referred to before undertaking a
medication history to ascertain background information about the patient.
 Check that any written information you look at is for the patient you are dealing with
and that the information is current.
 You must use at least one of the following sources to provide a medication history.
o Patient
o Patient’s own drugs
o GP surgery
 Ensure that any special requirements such as liquids, MDS information or other is
communicated effectively following Trust procedure to aid supply and discharge.
1. Coherent Patient
The patient should be able to confirm with you what medicines they have actually been
taking before admission. Some patients do not always remember all their medication
when they are first admitted, especially if they are acutely unwell. A coherent patient with
their own medication is the ideal source to obtain a medication history from. You can
then go through each medication the patient has brought into hospital confirming dosage
and exactly how that patient takes each medication. This is an ideal opportunity to
identify any potential compliance issues.
2. Patients own medication brought into hospital
These should be used in conjunction with the patient or carer including compliance aids
or compliance aid inserts.
Patients may not bring all their usual medication into hospital. Patients may also bring in
medicines that have been stopped or those that belong to a relative. Remember
Dossett® box inserts are not a comprehensive list of all medicines a patient may take. If
the patient is unable to give you further information, always confirm the medication
history with another source as well. If in any doubt that a medication is missing, consult
another source.
Always check the dispensing date on any medication brought into hospital.
3. Patients handwritten list
A handwritten list is a good source to use in conjunction with another source, ideally the
patient. The quality of the information included can vary, and you may need to contact
the GP surgery for further information.
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4. Patients Relative/carer
They may be a useful source if the patient does not look after their own medication.
However, carers may not always know all the medication a patient takes. There can be
ethical issues regarding discussion with family or a carer - discuss with your trainer.
5. GP repeat prescription slip
Always check the number of pages to ensure none are missing.
Check the last issued date as stopped medication can often remain on the repeat
prescription list.
Always query ‘not issued’, this can mean many things e.g. supplied from hospital,
prescribed at a home visit or never issued. GPs review repeat medication prescriptions
every 6 - 12 months. The issue is often re-set to zero when this is done.
Recently issued ‘acute’ items will not be included on the repeat prescription list so you
may need to ask the patient or use another source to find this information.
6. GP surgeries
Take care when taking information from receptionists. They often read a list from a
computer and have no drug knowledge. Be careful to clarify if and when items have been
issued and ask for the type and device of inhalers and insulin, and check whether
something is a modified release preparation (e.g. MR, LA, XL, SR). Always ask the
receptionist to check if any recent acute prescriptions have been issued and check the
allergy status. Controlled drugs may not be included on the computer system as these
may be hand written rather than printed. Information obtained over the phone should be
followed up with a fax.
If the patient does not know which GP practice they are registered with, check on the
Patient Administration System (PAS).
7. GP printout
There are a number of computer systems used by GP surgeries and the quality of the
information provided can vary. Ensure all the information required to obtain a medication
history is provided. The ‘quick glance’ summaries provide a list of medicines which may
or may not be current and do not include the dosage details. Some printouts list recent
consultation which can confirm useful information e.g. acute issues or why medicines
have stopped/started.
8. GP letter
The quality of the information provided in GP letters can vary. Remember if the GP
visited the patient at home he will not have access to the computer records, therefore
any medication history information could have been from memory. It is best practice to
check with another source.
9. Care home Medication Administration Record (MAR) chart
Usually printed out by community pharmacies to use in care homes, they are often sent
with the patient or faxed to the ward on admission and filed in the medical record. These
can be an excellent source of information as they are used in a similar way to drug
charts. The home can be contacted for clarification of strengths/doses etc. that are not
clear. Common mistakes made with this information source are forgetting to check the
directions, the frequency or times of administration and along the administration column
to see if anything has been stopped.
Always check you have all the pages and the information is for the correct patient.
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Take care with hand written MAR charts, always confirm with another source.
Remember to check the nursing home database for community pharmacy and supply
details. Document how medication should be supplied at discharge.
10. Community pharmacists
Some patients do not use the same community pharmacy for every prescription so they
are not usually the best source of information.
For patients who have a compliance aid filled by a community pharmacy, contact the
pharmacy on admission. Their details, name, telephone and fax number and type of aid
should be recorded on the front of the drug chart and in the medication history.
Also document if the patient has a compliance aid filled by themselves or a carer.
11. HomeCare Medicines Administration Record (MAR) chart
Some patients who have homecare (paid carers) to assist them taking their medication
may have their medication supplied in boxes and bottles, but have a printed MAR chart
from their community pharmacy. The printed MAR chart can be used as one source for
the medication history. As with compliance aids the details of the community pharmacy
should be recorded on the front of the drug chart and in the medication history.
12. Discharge Advice Notes (DAN)
If the patient has been in hospital within the last month or so, information from discharge
advice notes (DAN) can be used as one source.
If a patient has been recently in hospital the GP computer system may not have been
updated with any changes made to the patients’ medication. Every effort should be made
to access a copy of the recent DAN from the patients notes, or from pharmacy (if
necessary archived DAN can be retrieved), or from an electronic discharge advice note
programme.
Remember, if a medication history was not confirmed on the admission to which the
DAN relates, then the DAN may be inaccurate.
13. Clinic letters
Can be found in the patient’s medical record, or obtained from the consultant’s secretary.
Clinic letters however, can contain information regarding specialist medication prescribed
by the consultant, but the medication history is often inaccurate.
14. Treatment Advice Notes (TAN)
If a patient has been seen in an outpatient clinic they may have been issued a TAN
instead of a prescription, always check with the patient if this medication has been
started.
15. Clinics e.g. warfarin clinic, dialysis, diabetes.
It may be necessary to contact the consultant, their secretary or the administration staff
at the clinic to find out details of a patients particular medication. Inevitably this
information will need to be used in conjunction with other information sources.
Warfarin dose; look on the results server DAWN7® or ring the anticoagulation clinic for
dosage information if the patient does not know.
Renal patients; it may be necessary to contact a renal pharmacist.
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16. Homecare prescriptions
Some medication is supplied through homecare services rather than being supplied from
the hospital or GP e.g. some renal medication, HIV medication, immunosuppressants.
You can contact the specialist pharmacist for details. Record on the front of the drug
chart if homecare services are used.
17. Addiction services
Addiction services usually prescribe medications related to addiction treatment only.
Contact them as you would a GP surgery, but remember the patient may be on other
medication prescribed through their GP as well.
18. Pharmacy computer systems
The pharmacy computer system should not be used as a lone source to obtain a
medication history. It is not a patient medication record and can contain inaccurate
information. However, if you are unable to access information from other sources it is
sometimes useful. It may also give a date when a Discharge Advice Note (DAN) was
done and is useful as a starting point to help hunt down a copy of a DAN
19. Mental health services
Patients may have some medication prescribed from a mental health service in addition
to those supplied by their GP. In order to gather this information you may need to speak
to the secretary of the consultant the patient is under or their CPN (Community
Psychiatric Nurse).
20. Clinical booklets e.g. Methotrexate, cardiology books
Useful source when used in conjunction with another source. However these may not be
kept up to date by the clinic or the patient.
Ideally you should encounter as many of these sources during your training as possible.
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Thinking Clinically
It is important to think about a clinical picture when undertaking a medication history.
Before you start the process of compiling a medication history look at the information you
already have about the patient to help you decide which the best source is to start with.
Look at the medical record. The amount of information available to you will differ depending
on the setting.
What is the reason for admission?
The presenting complaint (PC) will often help with clues for the medication history.
Examples
 Is the patient confused? If so they may not be a useful source.
 Exacerbation of COPD. The patient is probably on treatment for COPD already. e.g.
inhalers.
 Patient has taken an overdose? They may be emotionally labile; therefore, it is not
recommended that you ask probing questions about the medication they usually take.
 Patient has had a seizure. Are they epileptic? Are they on epilepsy medication?
Past Medical History (PMH).
Think about all of the patients medical conditions and what medication they may be treated
with.
Examples
 Diabetic patient; are they on diabetic medications (insulin, tablets) or are they diet
controlled?
 Asthma patients; are they on inhalers?
 Rheumatoid Arthritis patients; are they on immunosuppressants such as methotrexate or
infliximab?
 Patients with a psychiatric history may be under the care of a psychiatry specialist and
their GP may not have a record of their psychiatry medication.
 Patient with cancer; are they having chemotherapy?
Medication
For example
 If a patient takes folic acid six times a week, are they also on methotrexate?
 If a patient is on a bisphosphonate, do they also take a calcium supplement?
Check to see if the patient has brought any medication into hospital with them. Some of the
admissions booklets have a tick box for this. Look at the patient and their immediate
surroundings. Does the patient have any medication with them? e.g. inhalers or creams on
their table.
Patient Circumstances
Where does the patient usually live? Is the patient in a care home, sheltered housing or do
they live alone? This information is often recorded in the nursing notes section, and can
sometimes be found in the A&E clerking.
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Do carers administer medication? If a patient has just moved into a care home or CIC bed
(care in the community) they may have a new or temporary GP. If a patient has recently
moved GP practice, the new GP may not have a record of the patients’ medication.
Has the patient recently been discharged from hospital? Has the patient recently seen any
specialists, been to any clinics? This information could be recorded anywhere in the initial
clerking. In these circumstances the GP surgery list of medication may not be up to date,
and you may need to use additional sources e.g. recent DAN or clinic letter. (Remember; a
DAN is only an accurate source of information, if it’s complete, correct, and the medication
history and medicines reconciliation process had been completed for that admission).
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High Risk Medications
Warfarin
Detailed information should always be taken for patients on warfarin.
Technicians should inform the ward pharmacist if a patient is admitted on warfarin.
It is not acceptable to write ‘as directed’ or ‘as per INR’ in medication history.
Document the patients current dose. Ideally document indication, target INR, latest INR
result and date of next clinic appointment.
For the purposes of medicines reconciliation: if a patient is on a Dossett® box, state if
warfarin is in the Dossett® box or not.
How do you find this information out?
1. The majority of patients are managed through anticoagulant clinics which use a
central computer database software system (DAWN AC) but a small number are
managed by their own GP. Some pharmacists have access to DAWN AC directly on
the ward and can access all the required information through this.
2. Patients may have a print out with information or a yellow warfarin booklet.
 Ask the patient or their carer.
 Contact warfarin clinics
 Results server - listed as ‘dose and next appointment /INR’. Sometimes it is
difficult to see the decimal point - (sometimes a 0.5mg dose is displayed as
.5mg which could be misread as 5mg)
3. If patient is not a local resident and is unable to tell you themselves what their current
dose is you will have to ascertain how and where their warfarin is managed and
contact the relevant source.
Insulin
Insulin regimens are often documented inaccurately or incompletely in medical record. The
following information must be documented:

Brand

Administration device:

for those patients that say that they have an insulin pen, clarify between a prefilled disposable pen and a penfill cartridge.

Dose ‘as directed’ is not a dose. Write the dose in ‘units’ (not ‘u’ which can be
misread)
Some patients change their insulin dose depending on their carbohydrate (CHO) intake. This
should be recorded in the medication history.
How do you find this information out?
1. Information on dose can be found out from the patient, relatives/carer, district nurse,
diabetes clinic, blood glucose monitoring book, GP at surgery. GP receptionists are
often unable to provide this information.
2. Technicians - if you are unable to ascertain dose, inform the ward pharmacist.
Chemotherapy
Patients admitted to hospital wards on oral anticancer medicines are at risk from
uncontrolled prescribing, particularly when patients are admitted onto a non cancer services
ward.
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


If possible contact an oncology or haematology pharmacist to discuss the
chemotherapy.
A detailed medication history must be taken on admission, including:
o indication for oral anticancer therapy drug(s) and dose(s), frequency of
administration, e.g. daily, weekly, continuous or cyclical
o intended start date, duration of treatment, intended stop date for each cycle of
treatment and date of next cycle any supportive medications, e.g. antiemetics
Where possible, their own medication should be utilised for the remainder of the
cycle, thus minimising the risks associated with prescribing inappropriate / incorrect
doses or duration of treatment
Methotrexate
The National Patient Safety Agency highlighted methotrexate as a high risk drug, therefore
the ward pharmacist must be made aware of any patients admitted to the ward who are on
methotrexate.
This is prescribed once weekly. You must document:
 The day of administration, strength and number of tablets taken prior to admission.
 Any concomitant folic acid prescriptions should also be asked about.
 Check that this is correct on the drug chart and that the six days of the week when
the dose is not to be administered are crossed off - inform the pharmacist who can
suggest a course of action if this is not correct.
Remember to think clinically
Methotrexate injection may be prescribed by clinic therefore may not be on GP list.
E.g. Patient on folic acid 6 days a week but no methotrexate recorded?
Substance misuse (methadone and buprenorphine for addiction)
Patients who misuse drugs may exaggerate their daily intake of methadone, buprenorphine
or benzodiazepines (either prescribed or obtained illegally)
Medication histories for these patients MUST be confirmed with another source rather than
using the patient as the only source
 Confirm dose with the prescriber (this could be someone from an addiction service or
the patients GP), or the community pharmacy where they collect their prescription
from.
 Also determine and document
o the normal dispensing schedule - e.g. daily, weekly
o when the patient last collected their methadone or buprenorphine from the
community pharmacy
o if their dose is supervised
o dose, strength, formulation
o when the current prescription expires.
 Contact the community pharmacist to inform them of the admission. Document the
community pharmacies details, include name and telephone number on front of chart
and in the medication history
 Ensure methadone is documented by number of milligrams not number of millilitres
(since two different strengths of solution are available). This applies to ALL liquid
medicines.
 Patients do not usually get a supply of methadone on discharge.
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
The prescriber and community pharmacist will need to be contacted pre-discharge to
agree a plan of action
Opioids



Ensure the current drug, strength, formulation and dose are clearly documented
E.g. a patient may have several strengths of an opioid on repeat prescription, but
may not be taking all of them currently as doses can change.
Determine if patient uses any PRN or ‘breakthrough’ pain medication.
If a patient uses a pain relief patch confirm the day this is due to be changed. It is
good practice to confirm whether the patient has a patch on at time of admission.
Anti-epileptic medications


Some epilepsy medication needs to be prescribed using the brand name. Therefore
ensure the brand name is documented as well as the drug.
Patients should not miss any doses therefore if necessary contact the ward
pharmacist or technician to assist with ordering the medication.
Other medication to take particular care with
Parkinson’s medication
It is very important to ascertain drug, formulation and dose details to maintain usual regime
whilst in hospital

Ask the patient or carer/relative about timing of doses and document this.
 Patients should not miss any doses therefore if necessary contact the ward
pharmacist or technician to assist with ordering the medication.
Other once weekly medications
For example Bisphosphonates
 The day of administration should be confirmed with the patient and annotated on the
drug chart.
 Ask the patient whether they take calcium preparations and confirm which brand and
dose.
Steroids



It is important to obtain an accurate history regarding patient’s steroid dose.
Ask about any recent courses (within past 6 months). If they are currently taking any
steroids, ask how many and for how long (whether they were short 5-7 day courses,
reducing courses or maintenance dose).
For those on long-term steroids, annotate on the medication history so that treatment
is not abruptly stopped. The pharmacist can then annotate this on the drug chart.
Depot injections


Some patients may receive depot injections which may or may not be listed on their
repeat prescription list.
Psychiatric medication is sometimes given as a depot injection, and may be
prescribed by a psychiatry specialist rather than the patients GP. A patient’s CPN or
key worker may be able to provide further details.
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Patches


Always confirm how often a patch is changed e.g. changed weekly. Record the day
patch is next due to be changed.
Double check that the patient has a patch on.
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Allergy Status
An allergy is defined as a state in which the body becomes hypersensitive to particular
allergens. Reactions to an allergen can range from mild (e.g. a rash) to severe (e.g.
anaphylactic shock, which can be fatal).
A significant percentage of allergic reactions can be avoided.
Serious harm has occurred when patients have been administered drugs to which they have
a pre-existing allergy.
Prevention of such errors relies on patient allergy information being available at the time of
prescribing, dispensing and administration. It is therefore very important that when you
obtain a medication history for a patient you also clarify their allergy status.
The patient’s allergy status should be confirmed as soon as possible following admission. In
the medication history you should document:
 Approved drug name for drug allergens
 The nature of the reaction
 Ideally, if the information is available, the date of the reaction
The allergy history can be obtained from:
 Patient/carer
 GP surgery
 Care homes
 Hospital notes
The allergy status should be documented in the patient’s notes and on their drug chart.
The initial responsibility to obtain the allergy status of a patient lies with the clerking doctor, if
the allergy status cannot be determined immediately, (e.g. outside GP working hours or if the
patient is unconscious) there is a section on the drug chart in which the clerking doctor may
give authority for the nursing staff to administer medication (for 24 hours) without a
confirmed allergy status.
It is the responsibility of the doctor, nurse, pharmacist or pharmacy technician to ensure that
the allergy status for the patient is confirmed and documented as soon as possible.
Important:
If you discover a patient has been prescribed a drug to which they are allergic, you must
take action to alert appropriate medical nursing or a pharmacist before the next dose is due
to prevent a further dose being administered.
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School of Medicines Optimisation and Pharmacy, Health Education England working across Yorkshire and the Humber 2016©
Over The Counter medicines and herbal remedies
A complete medication history should take account of all prescribed and non-prescribed
medicines that a patient took at the point of admission.
Many patients do not automatically volunteer information about over the counter (OTC)
medicines or herbal/alternative remedies. The only way to find out if a patient takes any of
these products is to ask them.
A GP will generally not know that a patient buys OTC medication and this information will not
be recorded in the medical records. Patients who have to pay for their medication will often
buy products such as aspirin 75mg or painkillers (paracetamol, co-codamol, ibuprofen,
naproxen) from a pharmacy or supermarket as this is much cheaper than the cost of a
prescription.
Many patients associate herbal or alternative remedies as being safe because they are
‘natural’. However, these products can still interact with other prescribed medications and
cause adverse effects.
Many people do not realise that many medications they consider “conventional” were
derived from plants. Examples of this are aspirin (found in willow bark) and digoxin (found in
foxgloves).
Here are some examples of why it is important to know what herbal and OTC medicines
patients take.
 Cranberry based products, often taken by sufferers of recurrent UTIs, can interact
with warfarin. The Committee of Safety for Medicine (CSM) released advice in 2006
that anyone taking warfarin should avoid cranberries in any shape or form because of
this potentially fatal interaction. As well as being available to buy in herbal shops
cranberry is also an ingredient in some cystitis products that are available to buy GSL
so they can be bought without pharmacist advice.
 St John’s Wort, which is readily available in pharmacies and supermarkets, is taken
to improve mood. It can reduce the efficacy of the oral contraceptive pill leading to
unwanted pregnancies.
 Decongestant products which contain phenylephrine are available as GSL products
so can be bought from places like a supermarket without seeking advice about
interactions from a pharmacist. Decongestants can raise blood pressure and
hypertensive patients taking them long term can end up taking higher doses of their
blood pressure medicines.
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Documentation and Follow Up
Medication History Documentation
To conform to the NPSA/NICE medicines reconciliation alert, your organisation may have
developed a standard medication history document for recording medication histories. This
has been incorporated into many of the pre-printed admissions booklets (documentation
may vary depending on your organisation’s procedures).
In areas where a pre-printed admissions booklet is not used, the documentation sheet
should be used as a stand alone sheet and filed in the medical record. This document
should be used by any member staff undertaking a medication history. It is not a pharmacy
only document (this may be different for each organisation).
A common sense approach should be adopted when a member of the pharmacy team
verifies a medication history started by a Doctor which has not been recorded on the
standard documentation.
Duplication of work should not occur, and it may be more appropriate to amend the
medication history already written rather than re-writing the whole list on the medication
history documentation. However, if there is limited room in the section where the doctor has
recorded the drug history, write ‘See new entry made on … (date).’ and enter the complete
list in the next chronological space or on the medication history form.
Remember:
 Do not use abbreviations for strengths, write micrograms, units in full.
 Always document generic drug names and add brand names where appropriate.
 Document exactly what you have done and where the information has come from.
 Sign, print name and job title, and add date to what you have documented
 If you are unable to complete a comprehensive medication history, you must
sign/date what you have done and state what needs doing to complete it.
 Pharmacy staff must also sign and date the section on the front of the drug chart if a
medication history has been completed.
 Pharmacy staff should document in the PCP section, on the front of the drug chart, if
the patient uses a compliance aid and the type of device used. Details of the
community pharmacy and telephone and fax number should also be recorded here.
Record on front of drug chart when the community pharmacy has been informed of
the patients’ admission to hospital.
 Document in PCP section if patient lives at residential or nursing home.
Any written information sources used to obtain the correct medication history should be filed
in the patient medical record.
Once a medication history has been obtained, the next step in the medicine reconciliation
process is to check the patients’ drug chart. The role and responsibilities of the pharmacist
and the pharmacy technician may differ depending on the organisation (some explanations
are provided below as guidance only).
Documentation of Omissions or Discrepancies
An omission or discrepancy between the medication history and the drug chart could be
intentional (that is, a doctor has purposefully changed the patients medication) or
unintentional.
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School of Medicines Optimisation and Pharmacy, Health Education England working across Yorkshire and the Humber 2016©
Discrepancies between the drug chart and the medication history must be communicated to
the ward Pharmacist (refer to local policies and procedures). Each clinical area must decide
the best method of communicating this information to the clinical pharmacist. This may
involve using the pharmacist handover sheet.
In addition annotate in the PCP section on front of the drug chart “see medication history in
notes”.
Pharmacists must document all unintentional discrepancies in the current section of the
medical record which must be verified, signed and dated by a registered pharmacist. Where
the discrepancy would be deemed to cause harm if not resolved before the next dose, a
doctor must be contacted to resolve the discrepancy. If the discrepancy would not cause
immediate harm to the patient and the pharmacist is unable to rectify the error straight away,
annotate in the PCP section on the front of the drug chart ‘see medication history in notes’.
Writing in medical record (see your local SOP)
Note: pharmacists (and in some organisations appropriately trained pharmacy technicians)
can make an entry in the medical record regarding discrepancies surrounding the medication
history.
Out of hours
It is recognised that out of normal working hours obtaining a medication history may be more
difficult. However, every attempt should be made to confirm the medication history.
If you are unable to fully confirm the medication history for a patient, you must document
what information you have obtained, sources used, and what needs following up.
E.g. medicines in electronic systems checked, to contact GP on Monday for other
medications or confirmation, sign and date what you have documented.
This information should also be recorded on the front of the patients drug chart.
Incidents that could cause harm and near misses.
Remember to record any near misses resulting from medication histories on the local
reporting system in use at your trust.
An incident report form may need completing in certain circumstances. This should be
discussed with the ward pharmacist first.
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School of Medicines Optimisation and Pharmacy, Health Education England working across Yorkshire and the Humber 2016©
Checklist for taking a medication history
Remember:
Use a structured, patient centred approach to your consultation
Create a suitable environment for open and confidential discussion
Obtain valid consent from the patient (or carer) in accordance with trust procedures
Use safe systems to ensure correct patient identification and accurate communication
Use a range of sources of information, which must include:
 Patient
 Patient’s own drugs
 GP surgery
Record details of ALL medications being taken which must include:
 Medication name
 Form
 Strength
 Dose
 Frequency
 Allergies / intolerances
 Specific patient requirements (e.g. compliance aids, no clic-loc lids, etc.)
 Whether repeat medication or acute medication. If acute then document when
prescribed and for how long (steroids/antibiotics etc.)
Record the individual’s social habits where applicable, which could include:
 Tobacco usage
 Alcohol intake
 Recreational drug usage
Identify and document any medication related problems that the patient may have, which
could include:
 Compliance issues
 Adverse drug reactions
Document any new prescriptions or medications stopped or altered
Consider whether the drug history is adequate or whether further action required. If there is
uncertainty over the completeness of the drug history consider using other sources of
information
Record details of any discrepancies found when taking a medication history
Liaise with the appropriate people to resolve queries/ unexplained/unintentional changes
Ensure a clear and accurate history is documented
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School of Medicines Optimisation and Pharmacy, Health Education England working across Yorkshire and the Humber 2016©
Practical Activities
Here are a number of tasks for you to complete. These tasks are mapped to NOS
PHARM29. Write down your answers and discuss them with your mentor.

Tasks I, J, and K are your Essential Reading and Activities Tasks-You should
do them first









A. The importance of Medicines History Taking
B. Advantages and Disadvantages of Sources
C. Examples of trust documentation
D. Read medicines alerts or policies
E. Medicines with similar names
F. Problem solving skills
G. Communication scenarios
H. Medication history taking Mocks x 4
L to S Discussions with Mentor
Local Assessment Observations
These local assessments must be set up to check the candidate’s understanding, skills and
competence before they undertake the assessments.
 Sources
The following can be performed as OSCE’s, used as role play in groups for training
 Talking to a patient
 Talking to a GP surgery (if applicable in organisation)
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School of Medicines Optimisation and Pharmacy, Health Education England working across Yorkshire and the Humber 2016©
Evidence No:
Task A The Importance of Medicines History Taking
Sign and date
The following examples help highlight the importance of taking a
comprehensive medication history and confirming the information with the
patient. Discuss with your mentor.
Patient 1
Prescription from GP
Warfarin 1mg ASD
Warfarin 3mg ASD
Warfarin 5mg ASD
(NB ASD = ‘as directed’ which is commonly used on GP systems ).
Event: Doctor prescribed 9mg OD on admission
Problem: Warfarin dosage information is not usually recorded on GP
computer systems as it is usually managed by an anticoagulant clinic. The
GP surgery prescribes all strengths of tablets to enable the patient to take
the dose prescribed by anticoagulant clinic.
Actual Dose: This patient actually takes warfarin 4mg OD.
Potential Outcome: The patient would receive more than double the dose
they require leading to the risk of severe bleeding with potentially fatal
consequences
Patient 2
Prescription from GP
Lamotrigine 50mg 3 tabs ASD
Event: On admission Doctor prescribed 150mg OD
Problem: On discussion with the patient it was found that they were on a
reducing dose.
Actual Dose: Lamotrigine 50mg OD
Potential Outcome: Lamotrigine is an antiepileptic, sudden changes in
doses are not recommended due to risk of seizure. The patient may have
been on a reducing dose due to experiencing side effects of the drug e.g.
liver impairment, severe skin reaction or be changing to another
antiepileptic.
Patient 3
Patients handwritten list states Methotrexate 7.5mg once weekly
Event: On admission doctor prescribed this and a nurse administered a
dose.
Problem: This was an old list. The patient had stopped taking
Methotrexate 5 months ago.
Potential Outcome: Methotrexate is a cytotoxic agent; it is commonly used
to treat rheumatoid arthritis. Patients taking methotrexate can become
immuno-compromised and require close blood monitoring.
Patient 4
Event: Patient admitted and the medication history was verified by a
member of pharmacy staff using a faxed GP print out and compliance aid.
Eight medicines were documented. No insulin listed on either source.
Documented in Past Medical History that patient was diabetic.
Problem: It was noted 10 days later that the patient should also have been
prescribed Insulatard insulin.
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School of Medicines Optimisation and Pharmacy, Health Education England working across Yorkshire and the Humber 2016©
Evidence No:
Outcome: The Insulatard was prescribed as soon as the error was
noticed. However, due to the lack of insulin for ten days the patient had
poor glycaemic control which resulted in a diabetic nurse referral.
Learning point: Remember to take into account the complete clinical
picture of the patient.
Poor blood glucose control as a result of not receiving insulin or oral
hypoglyceamics (e.g. metformin, gliclazide) can harm patients, affect
recovery rates, and delay hospital discharge.
Notes
I confirm that the candidate has demonstrated knowledge/learning/understanding from these
activities.
Candidate signature
Date
Mentor signature
Date
Assessor signature:
External verifier signature:
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School of Medicines Optimisation and Pharmacy, Health Education England working across Yorkshire and the Humber 2016©
Evidence No:
Task B Advantages and Disadvantages of Sources
Sign and date
For the following sources list the advantages the source provides when
completing a comprehensive medication history and any disadvantages
associated with that source.
Discuss your answers with your mentor.
1.
2.
3.
4.
5.
6.
Coherent patient
A recent DAN
A GP surgery repeat prescription slip
JAC (or other system) pharmacy records
A handwritten GP letter sent in with the patient out of hours
A MAR chart sent in with a patient from a nursing home or
residential home
Notes
I confirm that the candidate has demonstrated knowledge/learning/understanding from these
activities.
Candidate signature
Date
Mentor signature
Date
Assessor signature:
External verifier signature:
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School of Medicines Optimisation and Pharmacy, Health Education England working across Yorkshire and the Humber 2016©
Evidence No:
Task C Examples of organisational documentation
Sign and date
To accompany this workbook you should be familiar with the following
documentation that you will probably have to use to take a medication
history. You should take a look at/print out examples from your
organisation and make notes as necessary for your training. Explain the
documentation used in your organisation.
Examples to be provided:
Standard medication history form
Electronic or paper version of pharmacy handover record
Warfarin record/print out with blood results
MAR Chart
Discharge information (e.g. TAN, IDS)
Medical Terminology List
I confirm that the candidate has demonstrated knowledge/learning/understanding from these
activities.
Candidate signature
Date
Mentor signature
Date
Assessor signature:
External verifier signature:
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School of Medicines Optimisation and Pharmacy, Health Education England working across Yorkshire and the Humber 2016©
Evidence No:
Task D Read your local Medication Safety Alerts
Sign and date
Read your local Medication Safety Alerts
Notes
Write down the most recent alerts applicable to your organisation and make brief notes
I confirm that the candidate has demonstrated knowledge/learning/understanding from these
activities.
Candidate signature
Date
Mentor signature
Date
Assessor signature:
External verifier signature:
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School of Medicines Optimisation and Pharmacy, Health Education England working across Yorkshire and the Humber 2016©
Evidence No:
Task E Medication with similar names and different formulations
Sign and date
Fill in the following:
What are drugs below used for? What are the consequences to the patient
if administered instead of the intended drug?
Amisulpride / Sulpiride
Promazine / Promethazine
Zolpidem / Zopiclone
Escitalopram / Citalopram
Fluoxetine / Paroxetine
Amlodipine / Azathioprine
Olsalazine / Olanzapine
Maxidex / Maxitrol
Hydroxyzine / Hydralazine
Amlodipine / Azathioprine
Discuss with your mentor
I confirm that the candidate has demonstrated knowledge/learning/understanding from these
activities.
Candidate signature
Date
Mentor signature
Date
Assessor signature:
External verifier signature:
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School of Medicines Optimisation and Pharmacy, Health Education England working across Yorkshire and the Humber 2016©
Evidence No:
Task F Problem Solving
Sign and date
Here are some examples of common problems encountered when
attempting to complete a medication history. Have a think about what you
would do in each situation. Discuss your answers with your mentor.
Scenario 1
What would you do if a patient has:
 come from a Care in the Community (CIC) bed
 recently changed GP practices
 recently been admitted to a Nursing Home
 recently been discharged from hospital
 incorrect GP information on clerking
 a GP that is not in the local area
Think about what issues you may come across whilst doing this
medication history.
How might you resolve these issues?
Scenario 2
What would you do if you need to complete a medication history but the
GP surgery is closed?
Think about the following:
 It is a weekday, the surgery is closed for half a day, for example
they are running in house training or they do not open on a certain
afternoon
 It is after 5pm and the GP will not be open again until the following
day
 It is the weekend
Scenario 3
What would you do if a patient needs a medication history taking but is
unable to communicate effectively with you because:
 they are confused
 they are unconscious
 English is not their first language
Notes
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School of Medicines Optimisation and Pharmacy, Health Education England working across Yorkshire and the Humber 2016©
Evidence No:
I confirm that the candidate has demonstrated knowledge/learning/understanding from these
activities.
Candidate signature
Date
Mentor signature
Date
Assessor signature:
External verifier signature:
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School of Medicines Optimisation and Pharmacy, Health Education England working across Yorkshire and the Humber 2016©
Evidence No:
Task G Communication Scenarios
Sign and date
Work through the following scenarios and give examples of how you may
communicate with the relevant staff members. Discuss your answers with
your mentor.
Scenario 1
You are the ward pharmacy technician on the medical admissions unit and
undertake a medication history for a patient after the ward pharmacist has
left the ward.
You complete the medication history but the patient has yet to have a drug
chart written for him. The patient is epileptic and usually on anti-epileptic
medication.
After documenting the medication history what would you do?
Scenario 2
You are a pharmacy technician working on a ward and confirm a
medication history, you document this in the notes and review the drug
chart. The drug chart matches the medication history exactly. The ward
pharmacist is due to visit the ward in approximately an hour’s time.
How would you communicate what you have done?
Scenario 3
You are working as a pharmacy technician on a ward and amend a
medication history. When you review the drug chart one of the items the
patient usually takes is not prescribed on the chart. The pharmacist has
left the ward and is not due to visit the ward again that day.
Consider what you would do?
Scenario 4
You undertake a medication history for a patient and notice that the
patients allergy status on the drug chart states NKDA, however the patient
tells you she is allergic to penicillin. The pharmacist is not on the ward at
the moment.
What would you do? And how would you communicate and with whom if:
a. The patients drug chart did not have a penicillin written on it
b. The patient is prescribed amoxicillin
Make notes on the following page
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School of Medicines Optimisation and Pharmacy, Health Education England working across Yorkshire and the Humber 2016©
Evidence No:
Task G Continued
Scenario 1
Scenario 2
Scenario 3
Scenario 4
I confirm that the candidate has demonstrated knowledge/learning/understanding from these
activities.
Candidate signature
Date
Mentor signature
Date
Assessor signature:
External verifier signature:
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School of Medicines Optimisation and Pharmacy, Health Education England working across Yorkshire and the Humber 2016©
Evidence No:
Task H Example Medication Histories to Complete
Sign and date
This activity must include at least 4 example medication histories from
your organisation which contain problems and difficulties, which will test
your ability to complete a medication history.
Complete a medication history for each example given.
Write down the answers to the questions asked.
Discuss your answers with your mentor.
If your organisation is unable to provide these we have a set of four to work
through to support this training-however the processes may be out of date or
different to local procedures.
See booklet online: Example Medicines Histories for Training and Assessment
Available at: https://www.networks.nhs.uk/nhsnetworks/medslearning/documents/example-meds-histories-for-training-andassessment/at_download/file
I confirm that the candidate has demonstrated knowledge/learning/understanding from these
activities.
Candidate signature
Date
Mentor signature
Date
Assessor signature:
External verifier signature:
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School of Medicines Optimisation and Pharmacy, Health Education England working across Yorkshire and the Humber 2016©
Evidence No:
Task I Essential Reading Medicines Reconciliation - Procedures
and Policies
All candidates must be able to demonstrate a good working knowledge of locally agreed
standard operating procedures.
 List organisational and departmental procedures relating to Medicines Reconciliation
and Medicines History Taking.
 Read and make notes on areas you think are most important to your understanding
and learning. Discuss these with your mentor
Essential reading - Procedures and Policies
Date Completed
E.g. Medicines Reconciliation
Discuss local policies and procedures relating to Reconciliation of Medicines and Medicines
History Taking
E.g. Medicines History Taking
Discuss local policies and procedures relating to Reconciliation of Medicines and Medicines
History Taking
Insert title here
Notes for discussion:
Insert title here
Notes for discussion:
Add more as necessary
NOS Knowledge and understanding for SFHPHARM29 must be mapped here using the
correct procedures and policies to cover areas required.
Mentor’s Comments:
I confirm that the candidate has demonstrated knowledge and understanding of all relevant
procedures and their purpose
Candidate signature
Mentor signature
Assessor signature:
Date
Date
External verifier signature:
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School of Medicines Optimisation and Pharmacy, Health Education England working across Yorkshire and the Humber 2016©
Evidence No:
Task J Essential Reading Medicines Reconciliation - Procedures
and Policies
All candidates must be able to demonstrate a good understanding of the medicine
management role and Medicines History Taking
 Complete the essential reading list below.
 Make notes on the most important and relevant points for your learning and
understanding. Discuss these with your mentor.
Essential reading list
Date Completed
E.g. A spoonful of sugar-Medicines Management in NHS Hospitals
The Audit Commission Publications 2001
Notes for discussion:
Insert title and details here
Notes for discussion:
Insert title and details here
Notes for discussion:
Insert title and details here
Notes for discussion:
Add more titles (Trust specific)
This reading material where possible must map to knowledge and understanding of NOS
SFHPHARM29.
Mentor Comments:
I confirm that the candidate has demonstrated knowledge/understanding/learning from this
reading.
Candidate signature
Date
Mentor signature
Date
Assessor signature:
External verifier signature:
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School of Medicines Optimisation and Pharmacy, Health Education England working across Yorkshire and the Humber 2016©
Evidence No:
Task K Medicines Management Essential Activities
Complete the further reading list, include any local training/study days and CPD below. Make
notes on the most important and relevant points for your learning and understanding.
Discuss these with your mentor.
Further reading list
E.g. DOH Article 2012 Chief Nursing Officer
Date Completed
http://cno.dh.gov.uk/2012/02/29/making-medicine-management-multiprofessional/
Notes for discussion:
GPhC Standards of Conduct, Ethics and Performance.
http://www.pharmacyregulation.org/standards/conduct-ethics-andperformance
Notes for discussion:
Medical terminology and common abbreviations
(use organisations own examples)
Notes for discussion: Discuss the most common abbreviations and medical terminology
used in your trust
Add more/change titles (Trust specific)
Local Training and Study Days
Add training/study days
Date Completed
Notes for discussion:
CPD
Add cpd in progress or completed
Date Completed
Notes for discussion:
Depending on the content of the above-you should be able to obtain further maps to NOS
SFHPHARM29 knowledge and understanding.
Mentor Comments:
I confirm that the candidate has demonstrated knowledge/learning/understanding from these
activities.
Candidate signature
Date
Mentor signature
Date
Assessor signature:
External verifier signature:
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Documented discussions with mentor
As part of the evidence collection for your portfolio the following tasks must be completed
and added to your portfolio. Each task has been given a separate page below with evidence
number. You must complete the evidence index in your portfolio.
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School of Medicines Optimisation and Pharmacy, Health Education England working across Yorkshire and the Humber 2016©
Evidence No:
Task L Explain the terms: Medication
Reconciliation and Medicines Review
History,
Medicines
See pg 6&7 for guidance information
Notes:
I confirm that the candidate has demonstrated knowledge/learning/understanding from these
activities.
Candidate signature
Date
Mentor signature
Date
Assessor signature:
External verifier signature:
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School of Medicines Optimisation and Pharmacy, Health Education England working across Yorkshire and the Humber 2016©
Evidence No:
Task M Discuss overview of the process for medication history
taking
Notes
I confirm that the candidate has demonstrated knowledge/learning/understanding from these
activities.
Candidate signature
Date
Mentor signature
Date
Assessor signature:
External verifier signature:
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School of Medicines Optimisation and Pharmacy, Health Education England working across Yorkshire and the Humber 2016©
Evidence No:
Task N Explain what to do with omissions or discrepancies in
medication histories and how you would communicate these to the
appropriate people
Notes
I confirm that the candidate has demonstrated knowledge/learning/understanding from these
activities.
Candidate signature
Date
Mentor signature
Date
Assessor signature:
External verifier signature:
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School of Medicines Optimisation and Pharmacy, Health Education England working across Yorkshire and the Humber 2016©
Evidence No:
Task O Discuss what to do when obtaining a medication history
during out of hours
Complete if applicable to your organisation
Notes
I confirm that the candidate has demonstrated knowledge/learning/understanding from these
activities.
Candidate signature
Date
Mentor signature
Date
Assessor signature:
External verifier signature:
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School of Medicines Optimisation and Pharmacy, Health Education England working across Yorkshire and the Humber 2016©
Evidence No:
Task P Discuss how to record near misses resulting from
medication histories
Notes
I confirm that the candidate has demonstrated knowledge/learning/understanding from these
activities.
Candidate signature
Date
Mentor signature
Date
Assessor signature:
External verifier signature:
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School of Medicines Optimisation and Pharmacy, Health Education England working across Yorkshire and the Humber 2016©
Evidence No:
Task Q Explain your department’s procedure on incident reporting
Notes
I confirm that the candidate has demonstrated knowledge/learning/understanding from these
activities.
Candidate signature
Date
Mentor signature
Date
Assessor signature:
External verifier signature:
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School of Medicines Optimisation and Pharmacy, Health Education England working across Yorkshire and the Humber 2016©
Evidence No:
Task R Discuss your understanding of all listed high risk
medication and the most appropriate information source to use for
each
See pg 16 for guidance
Notes
I confirm that the candidate has demonstrated knowledge/learning/understanding from these
activities.
Candidate signature
Date
Mentor signature
Date
Assessor signature:
External verifier signature:
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School of Medicines Optimisation and Pharmacy, Health Education England working across Yorkshire and the Humber 2016©
Evidence No:
Task S Research and then discuss the following with your mentor




Describe the benefits of being trained to be a safe and effective medicines
management practitioner in relation to medicines history taking
Explain the basic principles of medicines history taking
Discuss the professional standards and responsibilities of pharmacy technicians in
delivering medicines history taking
You are expected to demonstrate compliance with relevant and current legislation,
policy, good practice, organisational and professional codes of practice and ethical
standards in personal practice
Notes
I confirm that the candidate has demonstrated knowledge/learning/understanding from these
activities.
Candidate signature
Date
Mentor signature
Date
Assessor signature:
External verifier signature:
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School of Medicines Optimisation and Pharmacy, Health Education England working across Yorkshire and the Humber 2016©
Evidence No:
Local Assessment Observations



Medication History Sources Observation Checklist
Observation of talking to a patient using assessment checklist (can be simulated e.g
OSCE)
Observation of telephone calls using assessment checklist (if applicable in
organisation)
Medication history sources - observation checklist
MEDICATION HISTORY SOURCE
DATE
SIGNATURE OF MENTOR
Patient
Patients own medication
Compliance aid insert
Patients written list
Relative/carer
GP repeat prescription list
GP surgery (over the phone)
GP printout
GP letter
Care home MAR chart
Community pharmacy (over the phone)
Discharge prescription (TTO/DAN)
Clinic letter
Warfarin clinic print out/ yellow book
Treatment Advice Note (TAN)
Homecare prescription
Addiction services (over the phone)
Pharmacy computer systems (JAC)
Candidate signature
Date
Mentor signature
Date
Assessor signature:
External verifier signature:
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School of Medicines Optimisation and Pharmacy, Health Education England working across Yorkshire and the Humber 2016©
Evidence No:
Talking to a patient - observation checklist
TALKING TO A PATIENT OBSERVATION
Achieved Y/N
Comments
Read the notes to acquaint themselves with the
patient and why they have been admitted
Introduced themselves to patient, confirm
patient’s identity, and ensure suitable
environment for discussion.
Explained purpose of visit to patient
Obtained consent to obtain medication history
Used effective communication skills relevant to
patients needs
If patient has brought in PODs
Did they confirm (where appropriate) with the
patient for each medicine
 If they still take it
 Dose they currently take
 Frequency they take it
 Formulation (MR, inhaler type)
 Is it a repeat prescriptions
 Is it an acute prescriptions
 Allergy status
If patient does not have PODs:
Can the patient confirm what they are taking
from memory?
If this is done, is the patient a reliable, coherent
source?
If there was any doubt about the medication
from talking to the patient have they decided to
try another source?
Obtained details of all non-prescribed
medicines/products and alcohol/smoking/drug
habits where applicable
Identified and reported patient compliance and
adherence issues
Confirmed patients understanding of process
and close discussion appropriately
Referred any issues outside personal limitations
Maintained patient confidentiality
Candidate signature
Date
Mentor signature
Date
Assessor signature:
External verifier signature:
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School of Medicines Optimisation and Pharmacy, Health Education England working across Yorkshire and the Humber 2016©
Evidence No:
Talking to a GP surgery - observation checklist
TELEPHONE CALL TO GP SURGERY
Achieved Y/N
Comments
Polite greeting used
 Introduce who they are (name and
occupation)
 Why calling
Did they use suitable patient identifiers?
 Date of Birth
 NHS number
 Address
If taking medication history over the phone:
Did they check (where appropriate)
 Drug
 Dose
 Frequency
 Formulation (MR, inhaler type)
 Date of last issue
 Repeat prescriptions
 Acute prescriptions
 Allergy status
Did they ask for a confirmation by fax if
appropriate?
If getting a fax (or confirmation fax):
Did they ask for all the relevant information to
be included?
 Repeat prescriptions
 Acute prescriptions
 Allergy status
Did they give the correct fax number?
 Was the number to hand?
For all phone calls:
Did they end politely?
 Say thank you
 Say goodbye
Candidate signature
Date
Mentor signature
Date
Assessor signature:
External verifier signature:
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School of Medicines Optimisation and Pharmacy, Health Education England working across Yorkshire and the Humber 2016©
Evidence No:
Appendix A Candidate Evaluation of Learning – Medicines
History Taking
Candidate’s Name
Job Title
Training:
Medicines History Taking Module – Medicines Management
Using the evaluation grids below, please score your skills and knowledge level both before
the training and after the training on a scale of 1 to 5 (with 1 being the lowest and 5 the
highest), and record on the grids provided.
Self assessment of skills level (Pre-program/Post-program)
Using this type of self-measurement of skills and abilities can be a useful tool in recognising
areas of strengths and weakness and where improvements can be/were made. It will also
help you realise what your level of understanding of the subject is after the training, and how
you can make real improvements in the future.
1. Complete questions 1, 2, which are about your scores
2. Complete question 3 which is a reflection and evaluation on the training you have
completed.
3. Save a copy in your portfolio.
Skill/knowledge level
before training program
(5 = highest level)
Skill/knowledge level after
training program
(5 = highest level)
5
4
3
2
1
5
4
3
2
1
5
4
3
2
1
5
4
3
2
1
Communications skills
5
4
3
2
1
5
4
3
2
1
Obtaining valid patient consent
5
4
3
2
1
5
4
3
2
1
Importance of range of sources
5
4
3
2
1
5
4
3
2
1
Importance of non-prescription
meds in history
5
4
3
2
1
5
4
3
2
1
Allergies and adverse reactions
5
4
3
2
1
5
4
3
2
1
High risk medicines
5
4
3
2
1
5
4
3
2
1
Documentation required/used
5
4
3
2
1
5
4
3
2
1
Self Assessment of skills level
Program Section:
SOPs relating to Meds Hist
Taking
Purpose of Meds Hist Taking in
MM role
Q1. Please briefly explain the above scores.
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School of Medicines Optimisation and Pharmacy, Health Education England working across Yorkshire and the Humber 2016©
Evidence No:
Q2. Which of the following may prevent you from applying the knowledge and skills learned
during the training? Tick all that may apply.
No opportunity to use the skills
Lack of management support
Lack of resources
Lack of support from colleagues and peers
Insufficient knowledge and understanding
Lack of confidence to apply knowledge and/or skills
Systems and processes within organisation will not support application of skills and
knowledge
Other
If other, please describe here:
Evaluation of your training
Q3.: What will you do differently because of your training? Provide up to 3 examples
Example 1
Example 2
Example 3
Thank You. Please put a copy into your portfolio and start a CPD cycle if you have identified
further learning needs.
Assessor signature:
External verifier signature:
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