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QH Safe Medication Practice Unit

Medication Reconciliation On Admission


Definitions

MEDICATION HISTORY The record of all medications a consumer is


taking at the time of hospital admission or presentation. It includes previous
adverse drug reactions and allergies and any recently ceased or changed
medications

CONFIRMATION The process of validating the completeness and accuracy


of the consumers current medication history, at the time of hospital admission
or presentation or as early as possible, with the consumer and where
appropriate their health care professional involved in their recent care

RECONCILIATION The process of comparing various medications lists to


avoid errors such as transcription, omission, duplication of therapy, drug-drug
and drug-disease interactions:
i. Comparing medication history with medications prescribed on
the medication chart
ii. Comparing discharge prescriptions with the medication history
and the medications prescribed
iii. Comparing discharge summaries with medication history,
medications prescribed and discharge prescriptions

MEDICATION LIAISON The process of ensuring continuity of care by


establishing well developed communication lines between hospitals and
community-based health professionals

The above definitions where compiled using the following resources: - Medication
Management Manual, Guiding principles to achieve the quality use of medicines and
continuity in medication management final draft, Society of Hospital Pharmacists
Practice Standards for Clinical Pharmacy and the JCAHO website

Copyright
Queensland Health supports and encourages the dissemination and exchange of information.
However, copyright protects this material.
Queensland Health asserts the right to be recognised as author of this material and the right
to have its material unaltered.
Use of material published by Queensland Health should be in accord with the Copyright Act
1968. Last updated December 2004.

T:\Zonal\S M P U\2. Medication Continuum\Guiding Principles\Principle 4 - Med History\Strategic Planning\Definitions v1.0.doc

QH Safe Medication Practice Unit

Guidelines for completing the Medication History & Reconciliation Form


U

Documenting the Interview


Document the medication information obtained on admission on the
Medication History & Reconciliation on Admission Form (MH&R Form)
Ideally a MH&R Form should be completed for every patient on admission.
Otherwise target selected patients (i.e. high risk patient), including those
specified in the APAC agreement i.e.
o Elderly > 65 years
o Taking 4 or more medications
o With a history of allergy or an ADR which may have contributed to
the admission
o With suspected poor level of adherence/compliance
o With impaired renal function
At admission, record
o GP and Community Pharmacy name and contact number
o All medication taken on admission generic name (trade name),
form, dose, frequency, trade name, duration, and indication using
the checklist provided
o Source of this information
o If own medications are available
nd
o Compliance issues in the Other Information box on the 2 page
of the form
o Any other relevant information
U

Medication
History
Interview

Confirmation
of the
Medication
History

Confirming the History


Confirm the medication history obtained on admission with the patient and
where appropriate with their community health care provider (i.e. for high
risk patients)
All histories are to be confirmed with a second source if possible using the
following hierarchy:- carer>family>nursing home>own
medications>Community Pharmacist>GP
Use the fax cover letter template to fax MH&R Form to Community
Pharmacist or GP for confirmation when required
Record the source and date of the confirmation
Record the Drs plan for each of the medications listed. Additional notes on
nd
reason for Drs plan can be placed in the Other Information box on the 2
page of the form
Sign and identify yourself as the person obtaining and recording the
information in the Signature and Profession column
P

Reconciling
of the
Medication
History

Reconciling
Check that each medication listed matches the medications prescribed on
the medication chart taking into consideration the Drs plan
Tick the reconcile column once the medication has been checked and
matches the plan (Do not mark this column until any discrepancy has been
adjusted or clarified and the medication has been reconciled i.e. matches
the plan)
Complete the Form
Complete the medication risk assessment
Tick and sign that the checklist provided was completed during the
medication history interview
Check all sections have been completed

The MH&R form should be kept with the active medication chart.
On discharge the MH&R form together with the medication chart should be used to reconcile the Discharge
prescription and referred to when producing a Discharge Medication Record for the patient, and for
Discharge Medication Liaison with GP, Community Pharmacy or Nursing Home.
T:\Zonal\S M P U\2. Medication Continuum\Guiding Principles\Principle 4 - Med History\Strategic Planning\User Guide for MH&R Form.doc
Version: 0.1
19/09/05

QH Safe Medication Practice Unit


After discharge the MH&R form should be filed in the medical record with the medication chart for that
admission.
Copyright
Queensland Health supports and encourages the dissemination and exchange of information. However,
copyright protects this material.
Queensland Health asserts the right to be recognised as author of this material and the right to have its
material unaltered.
Use of material published by Queensland Health should be in accord with the Copyright Act 1968. Last
updated December 2004.

T:\Zonal\S M P U\2. Medication Continuum\Guiding Principles\Principle 4 - Med History\Strategic Planning\User Guide for MH&R Form.doc
Version: 0.1
19/09/05

FAX MESSAGE
Insert name of hospital
Insert name of department or ward
Insert address
TO:

Fax:
Name:
Organisation:
Date:

Insert, Addressee's Fax No.


Insert, Addressee's Name
Insert, Addressee's
Organisation Title
Insert, Date

FROM:

Fax:
Phone:
Name:
Position:

Insert, Senders Fax No


Insert, Sender's Tel. No.
Insert, Sender's Name
Insert, Sender's Position Title

URGENT & CONFIDENTIAL PATIENT CARE COMMUNICATION


SUBJECT:

Confirmation of Medication History Profile


on Admission

Pages

No

(Inclusive)

Dear Doctor/Pharmacist,
Please see attached medication history list of .. As an accurate and complete medication
history is required to base medication management decisions on, your assistance by completing the actions listed
below, as soon as possible, would be appreciated.

ACTION REQUIRED:
1.
2.
3.
4.
5.
6.

Review the attached list of medications


Tick confirmation column if medication correct
Document any additions or amendments on the list
Place any comments in the section below
Fax back this cover sheet and confirmed list or phone
Other .

If you have any queries or require clarification, the pharmacist to speak to is . on the
phone number above. Your assistance and prompt attention to this request is greatly appreciated.
Kind regards,
Hospital Pharmacist
Comments

Please sign and return this form by facsimile to [Insert fax no.]
Dr/Pharmacist Signature__________________________________
Consent
I consent to the release of my medication list by Queensland Health or Community Healthcare Provider (eg. GP or
Community Pharmacy) to Queensland Health or my Community Healthcare provider.
______________________________
(Clients Name)

_______________________________
(Clients Signature)

________________
(Date)

This form is part of a QH Safe Medication Practice Unit initiative. Please contact Nina Muscillo (Project Officer) on 3636 9100 for information.
This facsimile is a confidential communication between the sender and the addressee. The contents may also be protected by legislation as they relate to health service matters. Neither the
confidentiality nor any other protection attaching to this facsimile is waived, lost or destroyed by reason that it has been mistakenly transmitted to a person or entity other than the addressee.
The use, disclosure, copying or distribution of any of the contents is prohibited. If you are not the addressee please notify the sender immediately by telephone or facsimile number provided
above and return the facsimile to us by post at our expense.
If you do not receive all of the pages, or if you have any difficulty with the transmission, please notify the sender.

(Afx patient identication label here)


URN:

MEDICATION HISTORY &


RECONCILIATION ON ADMISSION

Given names:
Date of birth:

Facility:..............................................................................................................

CHECKLIST

Family name:

ALLERGIES & ADVERSE DRUG REACTIONS (ADR)

Sign: ................................. Print: ............................. Date:

Medication
Generic name (Trade name) / Form / Strength

T
O

R
O

Complementary medicines (e.g. vitamins, herbal or natural therapies)


Topical Medications (e.g. creams, ointments, lotions, patches)
Inserted medications (e.g. nose/ear/eye drops, pessaries,
suppositories)
Injected medications
Recently completed courses of medication
Other peoples medication
Social and recreational drugs

MEDICATION LIST LEGEND


Source of
information:
GP: General
Practitioner
CP: Community
Pharmacist
P:
Patient
C:
Carer
NH: Nursing Home
OM: Own meds
CN: Community
Nurse

Professions:
RN: Nurse
MO: Medical Ofcer
HP: Hospital Pharmacist
RIPEN: Rural and Isolated
Practice Endorsed
Nurse

Discharge Info:
OM: Own Med
PBS: PBS Item / Quantity
A:
Authority Script
H:
Hospital Item Only
S8: Controlled Drug
Doctors Plan:
:
Continue
w:
Withhold
:
Cease
: Change

MEDICATION LIST

Date of admission: .............................................................

SW 013 Pilot v1.00 06/2005

Dose

Frequency

How long
or when
started

M
D

Indication
(conrm with
patient)

I
N

Source
of information

Drs
Plan

R
T
S

Signature
& Profession

Reconcile

I
T
A

KEEP WITH ACTIVE MEDICATION CHART - DO NOT REMOVE

Date
Discharge
conrmed
Info
and Source

N
O

MEDICATION HISTORY AND RECONCILIATION ON ADMISSION

DO NOT WRITE IN THIS BINDING MARGIN

Nil known
Unknown (tick appropriate box or complete details below)
Drug (or other)
Reaction/Date
Initials

Patients GP: .................................................................................................................. Community Pharmacist: ........................................................................................

Prescription medicines
Sleeping tablets
Inhalers, puffers, sprays, sublingual tablets
Oral contraceptives, hormone replacement therapy
Over-the-counter medications
Analgesics
Gastrointestinal drugs (for reux, heartburn, constipation,
diarrhoea)

Date

Sex:

Source of information:
GP: General Practitioner
CP: Community Pharmacist
P:
Patient
C:
Carer
NH: Nursing Home
OM: Own meds
CN: Community Nurse
Professions:
RN: Nurse
MO: Medical Ofcer
HP: Hospital Pharmacist
RIPEN: Rural and Isolated Practice Endorsed Nurse

Discharge Info:
OM: Own Med
PBS: PBS Item / Quantity
A:
Authority Script
H:
Hospital Item Only
S8:
Controlled Drug
Doctors Plan:
:
Continue
w:
Withhold
:
Cease
:
Change

(Afx patient identication label here)


URN:
Family name:
Given names:
Date of birth:

Sex:

MEDICATION LIST
Date

Medication
Generic name (Trade name) / Form / Strength

Dose

Frequency

I
M
D

Are patients own medications available?


Yes, all
Yes, some
No
Comments (where are they?): .........................................................................................

Source
of information

S
I
N

Drs
Plan

Signature
& Profession

Reconcile

A
R
T

Date
Discharge
conrmed
Info
and Source

N
O
TI

Checklist Completed:
Signature: ........................................................................................ Date: .................................

OTHER INFORMATION - RECENTLY CEASED OR ALTERED MEDICATIONS - COMPLIANCE


Assess compliance by asking: 1. People often have difculty taking their pills for one reason or another.. have you had any difculty taking your pills?
2. About how often would you say you miss taking your medicines?

MEDICATION RISK ASSESSMENT


Level of Independence
Looks after own medication
Carer looks after medication
Uses dose administration device i.e. spacers, inhaler devices

Patient Assessment
Can read
Can see/read labels
Can understand English

Uses administration aid (specify): ..................................................................................


Uses medication record
Fully dependent on others (e.g. lives in Nursing Home)

If no, language spoken is: ......................................................................................................


Can open bottles
Yes
No
Can measure liquids
Yes
No
Not an issue

Other information: ................................................................................................................................

Other information: ................................................................................................................................

Yes
Yes
Yes

KEEP WITH ACTIVE MEDICATION CHART - DO NOT REMOVE

No
No
No

DO NOT WRITE IN THIS BINDING MARGIN

A
R
O
F
T
NO

Indication
(conrm with
patient)

How long
or when
started

Medication History and


Reconciliation on Admission Pilot
AIM: To introduce A Systematic Approach To Obtain Relevant Information On Admission To Inform Medication Management
Decisions
LENGTH OF PILOT: 8 WEEKS
WHEN:
WHO CAN I CONTACT:

PH:

WHO IT AFFECTS: Patients, Nurses, Pharmacists, Doctors & Ward Receptionists


HOW IT AFFECTS YOU:
1.
Patients involved in this pilot will have a Medication History & Reconciliation on Admission Form completed (see
instructions below) and kept with their active medication chart in the end of bed folder
2.
This is a multidisciplinary form : nurses, doctors and pharmacists may document items relating to the patients medication
use on admission
3.
The medication information obtained on admission is to be conrmed with the patient and where appropriate their
community health care provider
4.
On discharge the discharge prescription should be reconciled with the Medication History & Reconciliation on
Admission Form and the medication chart
5.
Information collected on this form should be used when preparing a Discharge Medication Record (DMR) for the patient,
GP, Community Pharmacy or Nursing Home
6.
After discharge the Medication History & Reconciliation on Admission Form will be led in the medical record with the
medication chart for that admission
WHAT IS MEDICATION RECONCILIATION: The process of comparing various medication lists to avoid errors such as
transcription, omissions, duplication of therapy, drug-drug and drug-disease interactions

HOW TO COMPLETE & USE THE FORM


1. Record GP and Community
Pharmacy Details
2. Take medication history using
checklist as a guide and
document all current
medications on admission
(include indication and
duration of therapy)
3. Record the source of
information:
use code eg P for patient (see
legend)
4. Record the Drs plan: use code
eg. for continue
5. Sign and record your profession
using code (person recording
history)
6. Reconcile i.e. tick that each
medication has been checked
against the active medication
chart and reects the Drs plan
7. Record date medication history
conrmed and state source
using code
8. Pharmacist to record any
discharge information if
necessary

j
k

r
k

lmnop q
11

12

9. Record if own medications were brought into hospital


10. Sign and date that checklist (step 2) has been completed
11. Record compliance issues, any recently ceased or altered medications and any
other information
12. Complete Medication Risk Assessment
13. Keep with the active medication chart
Template produced by Queensland Health Safe Medication Practice Unit

QH Safe Medication Practice Unit

Work Practice Flowchart


Legend
Green MOs, Pharmacists , RIPENs
Tan - MOs
Purple Pharmacists , RIPENs

Patient
Presents to
ED or Ward

MEDICATION
HISTORY

1. Conduct medication history interview


2. Document on Medication History &
Reconciliation on Admission (MHR) form
3. Place sticker in Patients Progress Notes

CONFIRMATION +/MEDICATION LIAISON


Confirm with any
2 nd source
(Confirmation )

Is the patient a high risk


patient ? (refer to guidelines )

YES

Confirm with the previous


Healthcare professional /s
+/- carer (Confirmation +
Medication Liaison )

Any discrepancies or
queries between
sources ?
Document in
Date confirmed
and source
column on form

NO

YES

Obtain clarification
from patient or carer
and document on
form

RECONCILIATION
1. MO to decide plan for each
medication
2. Document this plan in the Drs
Plan column on the form using
the supplied legend

Has the Drs plan


been recorded ?

YES

NO
Where?
Liaise with Medical
Officer and
document on form

MO to write medications on
to the Medication Chart in
accordance with the plan
Recorded in
the medical
notes
1. MO to check each medication
listed on form has a plan which
coincides with the Medication Chart
2. MO to tick the Reconcile column
on the form

On form

Transfer to the
Drs plan
column on the
form

Medication History and


Reconciliation on Admission
form kept at end of bed with
the Medication Chart

Check each medication


listed has a plan which
coincides with the
medication chart and tick
the reconciliation column
on the form

Copyright
Queensland Health supports and encourages the dissemination and exchange of information.
However, copyright protects this material.
Queensland Health asserts the right to be recognised as author of this material and the right to
have its material unaltered.
Use of material published by Queensland Health should be in accord with the Copyright Act
1968. Last updated December 2004.