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East and South East England Specialist Pharmacy Services
East of England, London, South Central & South East Coast
Directorate of Clinical Pharmacy
A template policy for medicines reconciliation
CONTENTS
PAGE
NUMBER
Explanatory Notes
2
1.0 Definitions
4
2.0 Levels of medicines reconciliation
7
3.0 Process
10
4.0 Training and Accreditation
12
5.0 Standards
13
6.0 Future aspirations
15
Appendix 1: Criteria for referral for Second and Third Level
16
Medicines Reconciliation
Appendix 2: Checklist to support process of medicines
18
reconciliation
Appendix 3: Collecting information for medicines
19
reconciliation
Appendix 4: Collecting information for medicines reconciliation
23
Working group members
26
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Explanatory Notes

This policy has been worked up by a small group of volunteers from the
Clinical Pharmacy Network. We are very grateful for their hard work and for
their own local policies which they shared with the group and which have been
incorporated into this template. Our aim is that this template will act as a ‘gold
standard’ for setting out how effective pharmacy-led medicines reconciliation
(MR) must be delivered if the beneficial patient outcomes are to be achieved;
however, we also recognise it is a work in progress and we shall strive to
improve it further with your feedback

It is also recognized that all medicines reconciliation should be verified by
pharmacy; however, this may not always be possible due to limited pharmacy
opening hours and/or limited availability of appropriately trained staff. This
policy has therefore been designed to acknowledge this and ensure that
services are prioritized to those patients with greater need.

The group recognises that trusts across the geography will have very different
starting points for delivering MR, with some trusts currently carrying out only a
few MRs on selected wards, whilst others manage 80-90% coverage of all
admitted patients. This policy should help each trust to set out a policy that
defines the local service, but also sets an aspirational policy which can be
used to work up a business case for more staff, or to underpin service
redesign in order to redirect staff time to this priority activity

The document is intended to be used to support trusts to deliver a policy on
MR for all adult admissions by December 12th 2008. It thus contains just the
elements we consider appropriate for inclusion in a trust-wide policy. Some
trusts may feel it is appropriate to add further information, such as the benefits
of medicines reconciliation

Each trust should consider the document recommendations in the context of
their own local policies and working practices. When it is felt local
consideration of issues are particularly important this has been stated in italics

Medicines reconciliation as set out in the NPSA document is essentially a
technical process. As pharmacists we are aware that there is an important
clinical aspect to reconciliation. This has been incorporated into the policy
through the defining of levels of MR; however, we acknowledge that much
work still needs to be done to clarify this concept and the working group will
continue to meet (see Section 6)

If you have any policies or material which might support the writing of the
referral pathways ( Appendix 1) or to add to the Checklists, we would be
grateful if you would share them
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
The next steps for the group include:
o Incorporating comments from the Clinical Pharmacy Network
o Further clarification of levels of medicines reconciliation
o Identifying criteria that can be used to support defining standards
o Expanding and clarifying referral pathways between the various levels
of medicines reconciliation
The group welcomes comments on the content of this policy and its
implementation. Please email any comments to [email protected].
Mira Jivraj
Emergency Services Pharmacist, Northwick Park Hospital
Linda Dodds and Jane Nicholls
East and South East England Specialist Pharmacy Services
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1
DEFINITIONS
1.1
Medicines Reconciliation
Medicines reconciliation is a process designed to ensure that all medication a patient
is currently taking is correctly documented on admission and at each transfer of care.
It encompasses:



Collection of the medication history from a variety of sources (usually a
minimum of 2)
Checking that medicines prescribed on admission for the patient are correct.
The ‘checking’ step involves ensuring that the medicines and doses that are
now prescribed for the patient accurately reflect the sources consulted.
Discrepancies may be identified at this stage and these may be intentional or
unintentional.
Communicating any changes in medicines so that they are readily available to
the next person(s) caring for the patient. Communication must include reasons
for the change(s) and any follow-up requirements. Although the process and
outcomes may be verbally discussed with other members of the healthcare
team there must also be a written record in the patient’s medical record and/or
on the prescription chart as set out in Section 3.3.
Medicines reconciliation should involve pharmacists1. This means that systems to
deliver medicines reconciliation in different areas of care should be supported by
pharmacists and ideally involve pharmacy team members in a clearly defined
process.
1.2
Medication (drug ) history taking
Medication history taking encompasses: checking on allergies and sensitivities to
previously prescribed medication; documenting all regular and occasional prescribed
and non prescribed medications, including medicines recently started or stopped with
reasons for addition or discontinuation when known; side effects to current and past
medications; information on how the patient manages their medicines at home, for
example if they need the support of a carer, nurse or medication reminder device. A
full medication history should underpin the process of medicines reconciliation
1.3
Medication review
Medication review has been defined as a structured, critical examination of a
patient’s medicines with the objective of reaching an agreement with the patient
about treatment, optimising the impact of medicines, minimizing the number of
medication-related problems and reducing waste² ³.
A medication review can only be accurately performed once an accurate list of what
the patient is currently taking, i.e. medicines reconciliation, has been completed.
Medication review is a process requiring additional knowledge and skills to those
required for medicines reconciliation and so the two processes have been separated
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for the purposes of this document. The detailed processes involved in medication
review are considered beyond the scope of this policy.
1.4
Medicines Use Review
Medicines Use Review (MUR) is an advanced service within the NHS contract for
Community Pharmacy.
The specific aims of the service are to improve patient knowledge, concordance and
use of medicines by:
 •establishing the patient’s actual use, understanding and experience of taking
their medicines
 identifying, discussing and resolving poor or ineffective use of their medicines
 identifying side effects and drug interactions that may affect patient adherence
 improving the clinical and cost effectiveness of prescribed medicines and
reducing medicine wastage.
1.5
Discrepancies
Part of the checking process includes the identification of any discrepancies. A
discrepancy can be defined as any difference between the medicines the patient had
been taking in their previous care setting and the medicines prescribed in their new
care setting.
Discrepancies may be considered as:


Intentional
Unintentional
Intentional discrepancies can be defined as any difference between the medicines
the patient was taking prior to admission and the medicines prescribed in their new
care setting that have been changed intentionally and agreed with the clinician(s)
responsible for the patient's care.
Unintentional discrepancies (errors, omissions or unintentional additions) can be
defined as any difference between the medicines the patient was taking prior to
admission and the medicines prescribed in their new care setting that is not a
conscious change.
1.4
Patient medical record
Within each setting, this is the main record in which the clinicians record the patients’
diagnosis, treatment and responses.
1.5
Prescription chart
This refers to the chart used to record the prescribing and administration of
medicines during the inpatient stay.
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It is recognised that not all trusts will have a specific section in their current
prescription chart to record medicines reconciliation or medicines management
issues. Local decisions will therefore have to be made on how decisions and
information are recorded on these two sets of documents so that they are legible and
accessible to all members of the health care team. Such decisions should take into
account the fact that the patient medical record is the definitive patient record.
References
1. National Institute for Health and Clinical Excellence/ National Patient Safety Agency. Technical
patient safety solutions for medicines reconciliation on admission of adults to hospital. Department of
Health. December 2007.
2. Task force on Medicines Partnership and the National Collaborative Medicines Management
Services Programme (2002). Room for Review. A guide to medication review: the agenda for
patients, practitioners and managers
3. Clyne W, Blenkinsopp A, Seal R. A guide to medication review 2008. National Prescribing
Centre/Medicines Partnership Programme. 2008.
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2.0
LEVELS OF MEDICINES RECONCILIATION
2.1
Introduction
Medicines reconciliation (MR) is the responsibility of all staff involved in the
admission, prescribing, monitoring, transfer and discharge of patients requiring
medicines. MR can be considered to occur at different stages or ‘levels’ which may in
practice depend on the training and capability of the available staff, although ideally
should be driven by the needs of the individual patient. The staff carrying out MR at
any level must be appropriately trained and criteria should be clearly defined to
identify when and how a patient should be referred between the different levels.
Local decisions will need to be made about the level and content of training required
by non-pharmacy staff in order to optimise the Level 1 medicines reconciliation
process. Ideally this training should be led by pharmacy staff (Medication history
taking is a competency listed under F1 training). See also Section 4. .
2.2
Summary of levels of medicines reconciliation
Level
Brief description
Patient groups
First
Admission or
transfer-led
All
Referral criteria
to next level
Appendix 1
Second
Pharmacy
consolidation
Medication review
Defined (Section 5)
Appendix 1
High risk/targeted
patients
Not applicable
Third
2.3
Practical definitions
It is proposed that the pharmacy department will agree with clinical groups within the
trust which levels of service operate in each care area. It is recognised that pharmacy
staff may not be able to offer an MR service to every admitted patient within an
appropriate time frame because of limited opening hours and/or limited availability of
appropriately trained staff. It will therefore be necessary for any trust adapting this
policy to their own requirements to prioritise Level 2 and Level 3 services to meet
their local need. Those areas of care where Level 2 or Level 3 reconciliation is
deemed appropriate but not possible should be added to the trust risk register
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(a)
First Level - Admission-led
Patient
By whom
group
ALL adult
- Admitting doctor
admissions - Other healthcare
professional (who
has received
appropriate
training)*
Collection
Method
Using checklist as
a reminder
(Appendix 2),
supported by
appropriate
training*
Sources
Time frame
Preferably at
least 2
(Appendix 4)
Within 6 hours
of admission
* In areas of care where second level MR is not offered routinely, for example short
stay units such as the clinical decisions unit, the process must also include referral
for second level MR (pharmacy consolidation) if there are concerns about reliability
or accuracy of data collected, or third level MR (pharmacist review) if the patient is
locally agreed to be high-risk/targeted. Appendix 1 highlights criteria that may
prompt referral for second level pharmacy consolidation or third level pharmacist
review
(b) Second Level – Pharmacy consolidation
Patient
group
Agreed
adult
admissions,
utilising
guidelines
in
Appendix 1
to aid
prioritisation
By whom
- Pharmacists
- Accredited
members of the
pharmacy team
(may include
technicians and
pre-registration
pharmacists)*
Collection
Method
Using checklist
as a reminder
(Appendix 2),
supported by
appropriate
training.
Sources
Time frame
At least 2,
preferably 3
Within 48
hours of
admission (or
as agreed
locally)**
*Processes should be in place to ensure patients are referred for third level
pharmacist review if complex issues are identified
Although ideally all patients should receive Level 2 MR, it is acknowledged that this
may not be possible in current circumstances and patients may have to be prioritised
to receive this service.
**The working group considered that this should ideally be within 24 hours, and no
longer than 72 hours. This reflects the fact that information gathered after 72 hours
may be less relevant to the patient’s care
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(c)
review
Third Level - High-risk/Targeted patients requiring a pharmacist
Patient group:
Identified high-risk/targeted patients (Appendix 1). These will
include patients referred to a nominated pharmacist as a result of a first level or
second level medicines reconciliation
By whom:
Pharmacist
The detailed processes involved in medication review are considered beyond the
scope of this policy.
The East and South East Specialist Services clinical directorate are continuing work
to help define how patients might be prioritised for full medication review in different
care areas.
2.4 Referral of patients for different levels of MR



Where accurate medicines reconciliation has not been possible at first level,
and second level MR is not routinely offered, the admitting practitioner should
highlight the need for verification and refer for either a second level MR or
third level pharmacist review
The need for MR verification by the pharmacy team should be documented in
the patient’s medical record and on the prescription chart.
For criteria that may be used to prompt referral for a second level medicines
reconciliation (pharmacy consolidation) or a third level medication review see
Appendix 1.
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3.0 PROCESS
3.1 Collection and Checking
Information shall be gained from the patient and/or carer using an agreed checklist
and process (e.g. Appendix 2 & 3) and ideally corroborated by at least 2 reliable
sources (Appendix 4). For patients with communication difficulties caused by their
acute condition, sensory or cognitive impairment or language barriers, consideration
may need to be given to accessing additional sources, depending upon the individual
circumstances.
3.2 Communication
‘Communicating’ is the final step in the process, where any changes that have been
made to the patient’s prescription are documented and dated, ready to be
communicated to the next person responsible for the medicines management care of
that patient. Examples might include:
 When a medicine has been stopped, and for what reason
 When a medicine has been started, and for what reason
 The intended duration of treatment
 When a dose has been changed and for what reason
 When the route or formulation of the medicine has been changed, and for
what reason ( this is particularly important when, for example a patient is being
transferred from a high dependency unit to a medical or surgical ward)
 When the frequency of the dose has changed and for what reason
 Monitoring and follow up requirements, when these need to be actioned and
by whom
 The patient required support to take their medicines in a previous care setting
which may need to be resumed or reviewed.
(a) Communication following first level medicines reconciliation (admission
led). This is the responsibility of the admitting clinician



Documentation should always be made in the patient medical record, noting
sources used and dated and signed by the admitting practitioner
Prescription chart (as list of medicines to be administered)
Intentional medication changes should always be documented in the patient
medical record and on the prescription chart giving reasons for the change
(b) Communication following second level medicines reconciliation
(pharmacy consolidation). This is the responsibility of the pharmacist or
pharmacy technician who carried out the MR.

Intentional medication changes not already documented should be
documented in the patient medical record and on the prescription chart with
reasons for the change
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



Decisions may be taken locally as to when this is not required, e.g. when
following an agreed Integrated Care Plan that stipulates specific therapies
Unintentional medication changes should be discussed with the prescriber and
documented in the patient’s medical record and (if appropriate) on the
prescription chart with recommendations for follow up and dated and signed
by a pharmacist
Monitoring and follow up requirements identified during the medicines
reconciliation process should be documented in the patient medical record
(and prescription chart if appropriate) and dated and signed by a pharmacist
Verification of a level 1 medicines reconciliation should be noted on the
prescription chart and dated and signed by the practitioner who carried out the
MR
If communication difficulties are encountered and the patient is NOT used as a
source of information, this should be documented
Local policies should clearly state which members of pharmacy staff are
authorised to make entries on the prescription chart and in the patient medical
record, where these entries should be made and what they include (e.g., date,
time, signature, designation). Policies that enable entries to the patient medical
record to be made by a pharmacy technician should state whether they must be
countersigned by a registered pharmacist.
It is the responsibility of the person carrying out the second level medicines
reconciliation to ensure that:




Unintentional discrepancies highlighted by the MR are appropriately prioritized
and resolved. This may be through referral to another practitioner.
Any future transfer requirements between care settings are appropriately
documented in the patient medical record and where appropriate on the
prescription chart with any useful telephone numbers obtained on admission,
as these may aid a smooth transfer between care settings
To follow local trust policies on record keeping and documentation in the
patient medical record and on the prescription chart. As a minimum standard
documentation in the patient medical record should include patient details,
date, time, a summary of the actions as a result of the medicines reconciliation
and name, signature and contact details of the individual carrying out the
reconciliation. Where changes have been made to the prescription chart
these should also be appropriately documented.
Every effort should be made to ensure that medication changes and reasons
for the changes are communicated appropriately so that the person
discharging the patient can ensure the reasons for changes are
communicated at the next transfer of care
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4.0 TRAINING AND ACCREDITATION*


Staff carrying out first level MR should receive appropriate training which is
supported, delivered or led by the pharmacy department.* Face-to-face
training should be delivered by pharmacists
Staff carrying out second level MR will be accredited through an agreed
competency assessment to carry out the service. Training may be via a
locally or regionally agreed training package. Staff will be reaccredited at
agreed intervals.**
* Trusts will need to agree what first level training comprises and how it is delivered.
Ideally it will eventually be at least partly web based, agreed as mandatory for all
non-pharmacy staff who admit patients and access, and delivery monitored by a
package such as training tracker. Ideally training will be transferable between trusts
thus supporting a mobile workforce.
** Work is needed to clarify training and assessment requirements for pharmacy staff
undertaking second level MR. Ideally this will be agreed regionally or nationally.
Some work on taking this forward will be undertaken by the Clinical Directorate, East
and South England Specialist Pharmacy services.
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5.0 STANDARDS
It is considered likely that each clinical area/care group will need to be evaluated
separately within a trust, and the ratio between different levels of MR agreed based
on clinical need and pharmacy resource.
The following standards have been developed by the working group and may be
considered as a basis for local standards and audit of the agreed service.
PROCESS
Adult patients will have a Level 1 MR carried out as set out in the trust standard
operating procedure for MR within 6 hours of admission
STANDARD: 100%
Adult patients designated to require a Level 2 (pharmacy consolidation) MR will have
it carried out within 24 hours
STANDARD: 70%
Patients fulfilling criteria for a Level 2 MR in clinical areas where Level 2 MRs are not
routinely offered by pharmacy staff will be offered a Level 2 MR within an agreed time
of the referral being made
STANDARDS: 70% within 24 hours, 100% within 48 hours
The standards for Level 2 MR reflect the current constraints in many trusts with
respect to providing a service outside normal pharmacy working hours. The
standards would be expected to rise as pharmacy working hours are extended. An
alternative strategy would be to designate % to be completed within different time
frames, e.g. 70% in 24hr; 100% in 48 hr). Ideally targets should reflect clinical need,
however this may not currently be possible. Trusts should agree their standards for
individual care areas taking resources and clinical need into account.
DOCUMENTATION
FIRST LEVEL
Medications taken prior to admission should be documented in the patient medical
record together with the source(s) used to obtain the information
STANDARD: 100%
Intentional changes to medicines are documented in the patient medical record
together with reasons for the change
STANDARD 100%
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SECOND LEVEL
Confirmation of ratification of a Level 1 MR will be documented as set out as in local
policy
STANDARD : 100%
This recognises that some trusts do not yet have dedicated space on the prescription
chart for this information
Intentional medication changes will be recorded on the patient’s prescription chart as
set out in the local policy document
STANDARD : 100%
This recognises that this information may not be added to the discharge letter if
lodged only in the medical record
Identified unintentional changes to the admission medication will be recorded in the
patient’s medical record
STANDARD: 100%
Identified unintentional changes to the patient’s admission medication will be
resolved before discharge
STANDARD: 100%
Entries on the prescription chart and in the patient’s medical record related to the MR
process must be dated, signed and include a contact number for the member of
pharmacy staff making the entry
STANDARD 100%
Intentional changes to admission medication must be documented by the doctor or
nurse discharging the patient or a member of the pharmacy staff on the discharge
letter
STANDARD: 100%
Medicines discontinued on admission will have the reason for discontinuation added
to the discharge letter
STANDARD 100%
TRAINING
Staff providing Level I and Level 2 MR will receive training and accreditation as set
out in local trust policy documents
STANDARD: 100%
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6.0 FUTURE ASPIRATIONS





Criteria for referral by ward staff to second level (pharmacy consolidation)
(Appendix 1)
Risk assessment and redesign of services to ensure that high risk patients are
targeted and prioritized for level 3 services
Introduction of an accredited training program for medicines reconciliation
with reaccredidation at regular intervals
Training and accreditation standards for MR to be agreed across the East and
South England geography; however, in the meantime local training and
accreditation may be appropriate
Use of electronic learning tools to support training e.g. training tracker
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APPENDIX 1a. Proposed referral criteria for Second and Third Level Medicines
Reconciliation (based on work carried out at Hammersmith Hospital and by Nina Barnett,
Consultant Pharmacist, Harrow PCT).
These criteria should be adjusted to take into account the case mix in the
ward/unit
Type of Patient
This list is not exhaustive and there may be circumstances where a
patient does not fit any of the criteria below yet still needs a detailed MR.
PRIORITY
FOR 2nd level
MR
PRIORITY
FOR3rd level
MR
Patients whose medication is likely to have contributed to, or caused, the
current admission
High
High
Patients with complex medical history
High
High
Patients on drugs with a narrow therapeutic index, e.g. warfarin, digoxin,
lithium, phenytoin, methotrexate
High
High
Patients on opioids or other drugs with potential for abuse e.g methadone,
benzodiazepines
High
High
Patients who are on medication but don’t know names or doses,
especially those with >4 drugs or already have a compliance aid
High
Medium
Patients with communication difficulties (sensory or cognitive impairment,
language barriers
High
Medium
Patient with complex social1, physical2 or mental health3 issues that could
suggest poor medicines management
Medium
Medium
Straightforward drug histories e.g patients transferred from nursing
homes or other care settings
Medium
Low
Patients who have had significant or multiple intentional changes to their
medication
Low
Low
Patients with known adherence problems (or use medication reminder
charts) who would benefit from assessment for compliance aids
Low
High
Younger patients with no previous medical history
Low
Not required
Patients recently discharged and re-admitted for non-medication related
issues, e.g social
Low
Not required
Patients due to be discharged imminently where no changes have been
made to medication
Low
Not required
1
e.g. isolation, financial problems, low level of home support
e.g. impaired sight, hearing, dexterity, mobility, swallowing, communication (language or speech)
3
e.g. cognitive impairment, mental illness, confusion, learning disabilities, disorientation
2
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APPENDIX 2. Checklist to support process of medicines reconciliation
It is not intended that this checklist be completed on paper and stored for every
patient, rather that it underpins training around MR and practically supports the MR
process and guides the documentation that must be added to the patient medical
record or the prescription chart.
Patient details (full name, date of birth, weight, NHS/unit/hospital number, GP, date
of admission
The condition for which the patient was referred (or admitted) plus details of any comorbidities
Known allergies and nature of the reaction Should be signed, dated with
documentation of sources used
A complete list of all of the medicines currently being taken by the patient
Dose, frequency, formulation and route of all the medicines listed
Specific medication to ask about include
 Prn medication
 Inhalers
 Eye drops
 Topical preparations
 Once weekly medication
 Injections
 OTC medication
 Oral contraceptives
 Hormone replacement therapy
 Nebules
 Home Oxygen
 Herbal preparations
 Insulin
Additional information for specific drugs e.g. indication for medicines that are for
short-term use only (antibiotics), day of week of administration for once weekly
medication (bisphosphonates, methotrexate)
Medication management in own home e.g. details of specific support from carers,
dosette box, medication reminder charts
Sources used (minimum of 2) Should be documented
Name, signature and date of practitioner carrying out medicines reconciliation
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APPENDIX 3. Collecting information for medicines reconciliation
The ‘collecting’ step involves taking a medication history and collecting other relevant
information about the patient’s medicines. The information may come from a range
of different sources (some potentially more reliable than others). See Appendix 4.
The medication history should be collected from the most recent and reliable
sources. Where possible, information should be cross-checked and verified. The
person recording the information should always record the date that the information
was obtained and the source of the information.
This section covers:
A) Taking a medication history
B) A checklist of questions that can support medicines reconciliation and help to
identify any problems
The working party would like to acknowledge the policies developed at University
College Hospital, London, which underpin this appendix.
In developing local policies trusts will need to take into account local methodologies
for managing patients on the high risk drugs outlined.
A) THE PROCESS OF MEDICINES RECONCILIATION
This process may not be applicable for patients with communication difficulties. If a
carer or translator is not available, consideration should be given to relying solely on
a variety of external sources. In such cases, the difficulties in obtaining the drug
history, the sources used and possible areas of uncertainty must be clearly
documented

Introduce yourself to the patient and explain the purpose of your visit.

Confirm with the patient whether they have any medication allergies or
Adverse Drug Reactions (ADRs). Ask also about the nature of the reaction
and document this information in the patient medical record and the drug
allergy/hypersensitivity box on the medication record chart:
-
If the patient has no known drug allergies/hypersensitivities, then
document as ‘NKDA’
If the patient is unconscious/unavailable use other sources to determine
allergy status where possible.
This information should be signed and dated and include details of the
sources used

Ask the patient if they have brought their own medicines and/or a list of their
medicines into hospital.

Ascertain what medicines the patient was using regularly at their previous care
setting prior to admission (see Appendix 4 on Sources for Drug Histories).
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
Ask the patient for details of medicine name, formulation, strength and
frequency of administration for each medication.

Where the patient has been transferred from another care setting you may
need to check the medication history against the medication record chart or
administration record from that setting. You may need to use your discretion
and reconcile medicines from prior to admission to the previous care setting.

The first source of documentation of a medication history on admission should
always be the patient medical record.

In addition to asking the patient about regularly prescribed medicines, also
check if the patient is using any of the medicines listed in Appendix 2 as
these are often forgotten by patients.

Ascertain the patient’s adherence to their prescribed medication regime. Ask
the patient/carer if they take/administer the medicines as labelled. Ask if they
use a compliance aid.
Note: Some patients are confused on admission to hospital (especially the
elderly) and claim not to be taking any medicines. In such instances
alternative sources may define what medicines are prescribed and a view will
need to be taken on whether the patient complies or not.

Specific information should be collected about the following drugs:

Inhalers
- It is important to confirm the name, strength and type of inhaler.

Warfarin
- The following points should be recorded on the drug chart for patients
taking warfarin:
1. Indication, duration of treatment and target INR
2. Patient’s usual or most recent dose and time of day dose taken
3. Tablet strengths held by the patient
4. Whether patient has an anticoagulant “yellow” book
5. Date of last INR test and result (ideally record to be brought into
hospital)
6. Details of clinic that they attend for their monitoring and date of next
appointment

Steroids
- It is important to obtain an accurate history particularly for patients with
asthma or COPD, IBD or arthritis.
- Ask about any recent courses (within past 6 months) and if so, how
many and for how long (whether they were short 5-7 day courses or
reducing courses).
- For those on long-term steroids this should be annotated on the drug
chart so that treatment is not abruptly stopped.
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
Insulin
- The type (human, bovine or pork), brand, administration device and
dose should always be checked and annotated on the drug chart.
- For those patients that say that they have an insulin pen, clarify
between a pre-filled disposable pen and a penfill cartridge.

Oral contraceptives /HRT
- These are not always considered as medicines by the patient and
should therefore be asked for.
- Additional counselling may also be needed if antibiotics are started for
the oral contraceptive pill

Methotrexate
- This is prescribed once weekly so the day of administration, strength
and number of tablets taken should be confirmed with the patient.
- 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.
- Any concomitant folic acid prescriptions should also be asked about.
- Ask to see the patients monitoring booklet.

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.

Opioids
Confirm dose, brand, strength and colour of tablet
Frequency of use, recent dose changes
Confirm with GP if any concerns

Methadone
- Check whether doses have been confirmed with the Drug Treatment
Centre (DTC), patient’s GP or community pharmacy
- Refer to local policies (eg re urine tox screens)
- Contact the community pharmacist to alert them of the patient’s
admission and determine the normal dispensing schedule and when
the patient last collected their methadone (daily supervised, weekly etc)
- Ensure methadone is prescribed by number of milligrams not number of
millilitres (since two different strengths of solution are available)
- Patients do not usually get a supply of methadone on discharge.
- The GP, community pharmacist and DTC contact will need to be
contacted pre-discharge to agree a plan of action.

Nebulisers
- Identify whether the patient has own nebuliser and nebules at home and
document on the drug chart.
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B) A CHECKLIST OF QUESTIONS TO SUPPORT MEDICINES
RECONCILIATION AND HELP IDENTIFY ANY PROBLEMS

Does anyone help you with your medicines at home? If so, who? What do
they do?

Do you have any problems obtaining or ordering your repeat prescriptions
(NB: relative / carer might help)

Do you have a regular community pharmacy that you use?

Do you have problems getting medicines out of their packages?

Do you have problems reading the labels?

Some people forget to take their medicines from time to time. Do you? What
do you do to help you remember?

Some people take more or less of a medicine depending on how they feel. Do
you ever do this?

Most medicines have side-effects. Do you have any from your medicines?

Specific medication related questions such as have any medicines been
stopped recently or have any doses been changed recently?
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Appendix 4. Sources of Medication Histories
The following sources of medication histories are listed below in no order of
preference, as reliability can vary according to the situation. However it may be
necessary to use two or more sources to establish an accurate medication history.
The working party would like to acknowledge the policies developed at University
College Hospital, London, which underpin this appendix.

The Patient
- This is an important source as the patient will tell you exactly how they
take their medicines.
- Always try to establish how exactly a patient takes their medicines, as
this could be very different from the formal records.

Patients Own Drugs (POD’s)
- Encourage patients to bring in their medicines from home.
- Discuss each medicine with the patient to establish what it is for, how
long they have been taking it, and how frequently they take it.
- Do not assume that the dispensing label accurately reflects patient
usage.
- Check the date of dispensing since some patients may bring all their
medicines into hospital, including those stopped.

Relatives/carers
- Patients may have relatives, friends or carers who help them with their
medicines.
- This is common with elderly patients or with patients where English is
not their first language.
- Carers can be very helpful in establishing an accurate drug history and
can also give an insight into how medicines are managed at home.
- Be mindful of maintaining confidentiality

Repeat prescriptions
- Some patients keep copies of all their repeat prescriptions. Many of
these may include medicines that have been stopped.
- The date of issue should always be checked and each item confirmed
with the patient.
- If there is any doubt, the GP surgery should be contacted.

GP Referral letters
- These are not always reliable.
- They are often written by the on-call doctor and may be illegible or
incomplete.
- It may be necessary to double-check the drug history with the patient,
relative/carer or GP surgery.

GP surgery
- Ideally, a faxed list is preferable, especially if the receptionist appears
to be having problems pronouncing the drug names.
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-
-
Be aware of ‘acute medicines’, ‘repeat medicines’ and ‘past medicines’
on the receptionist’s screen.
Always check when the item was last issued and the quantity issued.
Specific questioning may be needed for different formulations, for
example different types of inhalers (metered-dose, breath-actuated,
turbohaler), different calcium preparations (Calcichew®, Calfovit D3®,
Adcal D3®), or medicines which are brand specific (aminophylline,
theophylline).
It may be necessary for you to speak to the GP directly to clarify any
discrepancies.
Specifically ask whether there are any ‘Screen messages’. Some
medications are ‘hospital only’ and do not appear on the usual ‘repeat
list’.

Compliance aids e.g. Dosette, Venalinks, Medimax.
- These may be filled by the community pharmacist, district nurses,
relatives or patient.
- If dispensed by a community pharmacist, the device should be checked
for dispensing labels which will provide the pharmacy contact details.
- The date of dispensing should also be checked bearing in mind that the
medicines may have changed.
- Remember to check for ‘when required’ medicines and medicines that
may not be suitable for compliance aids such as inhalers, eye drops,
once weekly tablets etc.
- Contact the community pharmacist to inform them of the patients
admission to prevent unnecessary repeat dispensing. They may also
inform you of the number of compliance aids that have been filled,
since these may still be at the patient’s home.
- The community pharmacist’s contact details should be documented on
the drug chart and a discharge plan agreed.

Medication reminder charts
- The chart should be checked through with the patient and the date of
issue noted.

Recent hospital discharge summary
- Check whether any changes have been made by the GP since the
patient’s previous discharge from hospital.
- If the patient has been home for more than two weeks it is likely that
they may have visited their GP and changes made.
- Discharge summaries that are more than one month old should not be
used as a sole source for a drug history.

Residential/Nursing home records e.g. Medication Administration Record
sheets.
- Useful and accurate source for a drug history.
- Usually sent in with the patient.
- Handwritten lists from homes should be used with care as they often
have transcription errors.
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In some cases it maybe necessary to investigate additional sources to obtain a
complete medication history. Examples of teams that may need to be
contacted for further information include:






Anticoagulant clinics
Community pharmacists
Specialist Nurses e.g. heart failure/asthma nurse
Drug and alcohol service
Renal Dialysis unit
Other hospitals for clinical trials/unlicensed medicines
Where possible, double check with the patient/carer as to how he/she takes the
medicines, as this may not be the same as on the prescription.
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Clinical Pharmacy Network MR Working Group Members
Mira Jivraj (Chair)
Emergency Services Pharmacist
Northwick Park Hospital
Linda Dodds
Associate Director of Clinical Pharmacy (South East Coast)
East & South East England Specialist Pharmacy Services
Anna Fletcher
Lead Pharmacist for Admissions and A&E ( St Mary’s site)
Imperial College Healthcare NHS Trust
Jane Hough
Pharmacy Clinical Services Manager Oxford Radcliffe Hospitals NHS Trust and
Associate Director Clinical Pharmacy East and South East Specialist Pharmacy
Services
Parmjit Jagait
Principal Pharmacist Clinical Services
Ealing Hospital NHS Trust
Rebecca Morgan
Medicines and Emergency Services Directorate Pharmacist.
UCL Hospitals NHS Foundation Trust
Jane Nicholls
Associate Director of Clinical Pharmacy
East & South East England Specialist Pharmacy Services NHS
Robin Offord
Director of Clinical Pharmacy
UCL Hospitals NHS Foundation Trust
Kiran Phal
Admissions Pharmacist
Ealing Hospital NHS Trust
Rebecca Willocks
Principal Pharmacist Medicines Safety
Barts and the London NHS Trust
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