Contents
1 Introduction
Please see the inpatient standard operating procedures (opens in new window) for how to record a medicines reconciliation and an allergy status within a clinical record.
This guidance forms part of the safe and secure handling of medicines manual.
In 2015 NICE published guidance NG5 medicines optimisation (opens in new window) that states when patients move between care settings, and the receiving team have prescribing or administration roles then a medicines reconciliation should occur.
- Medicines reconciliation will help ensure that all intended medication is given, all unintended medication is avoided, and the information transferred is accurate and contemporaneous.
2 Link to overarching policy
This document links to the overarching safe and secure handling of medicines manual.
3 Aim of the medicines reconciliation process
- To obtain and verify an accurate medication history for all patients on admission to a service.
- To maintain a contemporaneous record of current medicines and the reasons for addition, discontinuation, or alteration of the patient’s medicines during the inpatient stay.
- To provide accurate information of current medicines prescribed, including any changes, upon transfer of care for example, to the GP (general practitioner) upon discharge.
- Definition of medicines reconciliation.
- The National Prescribing Centre defines medicines reconciliation as:
- collecting information on medication history (prior to admission) using the most recent and accurate sources of information to create a full and current list of medicines, for example, GP repeat prescribing record supplemented by information from the patient and carer
- checking or verifying this list against the current inpatient prescription and summary care record and administration record in the hospital, ensuring any discrepancies are accounted for and actioned appropriately
- communicating through appropriate documentation, any changes, omissions, and discrepancies.
- In the community the reconciliation process should also indicate clearly who is responsible for prescribing the medication.
4 Summary of roles and responsibilities
4.1 Role of the prescriber (to include medical staff and non-medical prescribers (NMPs))
- To take a full, accurate medication history at the point of assessment on admission to the ward or team.
- To communicate with the patient or carer with regard to their usual medicines to ensure there are no discrepancies between the information obtained from the information sources and the patient or carer.
- To establish an allergy status and record this on the medication chart and on the alert sheet in the medical notes as documented in the overarching safe and secure handling of medicines manual.
- Only prescribe once the medication history is complete and accurate as to the persons current medication, doing so without this information is potentially hazardous.
- To complete and document the medication history with the information obtained.
- To document the reason(s) for any alteration in dose or frequency or for discontinuation of medication on admission on the medication history.
- To maintain an accurate, contemporaneous record for the addition, discontinuation and alteration of any medicines during the patient’s inpatient stay.
- To document any changes, discontinuations and additions of medicines on the patient’s discharge summary sheet.
4.2 Role of the pharmacist
- To verify that the medicines reconciliation process has been undertaken by the prescriber as soon as possible after the patient’s admission to hospital.
- To ensure the medication history appears complete and clinically coherent.
- To ensure the medication written on the current inpatient prescription and administration record matches that of the medication history, where appropriate.
- To ensure any discrepancies are documented appropriately in the patients record.
- To clarify any undocumented discrepancies with the prescriber.
- To verify the current medication chart, and highlight any discrepancies to the prescriber, and ward staff.
- To confirm and document allergy status, where appropriate.
- Where recorded allergies are thought to be inaccurate as request to mark in error should be made outlining the rationale.
4.3 Role of the ward based pharmacy technician
- To facilitate the medicines reconciliation process by establishing a medication history using appropriate resources in collaboration with a pharmacist.
- To record any additional information obtained on the treatment sheet.
- To inform the pharmacist, or prescriber where appropriate, of any discrepancies detected.
- To confirm and document allergy status, where appropriate.
4.4 Role of the nursing staff
- To highlight to a member of the medical or pharmacy team if they recognise any discrepancies between the inpatient prescription and administration record or and the patient’s regular medication.
- To ensure any information obtained is documented in the patient record.
- To ensure allergy status has been confirmed and documented in the allergy section of SystmOne prior to the administration of any medicines (unless in an emergency situation).
- To ensure any medicines prescribed are appropriate, after considering any allergy statuses.
4.5 Role of community team members (key worker)
- To take a full, accurate medication history at the point of assessment on admission to the team, for the patients under their care.
- To highlight to a member of the medical or pharmacy team if they recognise any discrepancies between what the record shows and what the patient is actually taking.
- To ensure any information obtained is documented in the clinical record.
- To ensure allergy status has been confirmed and documented in the clinical record, prior to medication being administered.
- To ensure any medicines prescribed are appropriate, after considering any allergy statuses.
5 The medicines reconciliation process
5.1 Sources of information
- Obtaining a full, accurate medication history requires access to one or more of the following sources:
- referral letter from primary care
- repeat prescription sheet from the patient
- electronic medication record from the GP practice
- GP surgery
- community pharmacy
- nursing home medication administration record (MAR sheet), care home and residential home
- patient’s relative and carer
- transfer from another unit or hospital
- recent hospital discharge letter and prescription chart
- patient’s own drugs
- patient
- In addition to using the sources listed above to identify prescribed medicines, the patient, relative or carer should be questioned with regards to over the counter medicines and alternative therapies they may be taking.
- It is important to establish if there are any discrepancies between the information obtained independently to the patient and the information that the patient delivers. Ideally, more than one information source should be used to obtain an accurate medication history.
5.2 Recording the medication history
This must be recorded on the appropriate section on SystmOne, please see the medicines reconciliation SOP (opens in new window).
5.3 Recording the medication history on admission
- Complete the medication history with:
- date of admission
- source of information using appropriate codes
- full name of the medicine and the formulation, for example, tablet, capsule, modified release preparation
- dose, frequency, and route
- sign and date the entry
- if any of the patient’s current medication is to be discontinued or altered on admission (for example, if the reason for admission is medication related), this should be documented with the reason for discontinuation or alteration and the entry signed and dated
- who is responsible for prescribing the medication?
5.4 Recording the medication changes during a patient episode
All medicines that are discontinued or altered during the course of the patient’s episode should have the reason for this recorded in the clinical record.
5.5 Communicating medication changes at discharge or transfer
- All significant changes to the medication that has occurred during a period of care, this includes outpatients settings, including medicines stopped on admission, must be recorded on the discharge summary, including allergy and sensitivity status, with reasons for those changes.
- A discussion about sending a copy of the discharge letter, to the patient’s community pharmacy, should be had with the patient.
5.6 Frequency of review
This should occur on admission to teams and wards, and in the case of community teams this should be updated each time medication is changed, and at least annually at the point of their annual review. Community patients should be reviewed on admission to services, and ideally annually.
6 Allergy status
The prescriber retains the principal responsibility for ascertaining allergy status of any patient for whom they prescribe. However, it is the responsibility of every person involved in the medication process, prescribing, dispensing or administration, to take every practical step to establish the allergy status of the patient. The only exception to this is in an emergency situation where this information is unobtainable and the risk of not treating the patient outweighs the risk of having the information needed to make a fully informed decision. It must be recognised that prescribing and administering medicines without establishing allergy status is potentially hazardous.
6.1 Assessment
- Take a history and undertake a clinical examination, using the guideline to help ascertain likelihood of it being an allergy. Please see appendix F of the safe and secure handling of medicines manual.
- Documenting and sharing of information with other healthcare professionals.
6.2 Record in their notes, and drug chart as
- Drug allergy and hypersensitivity.
- None Known Drug Allergy (NKDA).
- Unable to ascertain (must be documented as soon as information is available).
6.3 If an allergy has been documented include (where information is available)
- Drug name (generic and brand if known).
- Signs, symptoms, and severity.
- Date when it occurred.
6.4 New allergies identified whilst under our care.
- Drug name, generic and brand, strength, and formulation.
- A description of the reaction.
- Indication of the drug.
- Date and time of reaction.
- Number of doses or days prior to reaction.
- Route of administration.
- Which drug and classes of drugs to avoid in the future.
6.5 Maintaining and sharing drug allergy information.
- Ensure drug allergy and hypersensitivity is documented separately from adverse drug reactions so it is clearly visible.
- Included in all GP referral and hospital discharge letters.
- Ensure medicines reconciliation is carried out in line with NICE guidance.
6.6 Providing information and support to patients
- Discuss the persons suspected allergy with them and provide structured written information and record who gave this and when.
- Ensure the person is aware of what drugs or classes of drugs they need to avoid in the future and advise them to check with the pharmacist before taking over the counter medication.
- Advise them to carry this information with them, and to share this information whenever they visit a health care professional.
6.7 Non specialist management and referral to specialist services
- Consider stopping the suspected drug and advise to avoid in the future.
- Treat symptoms of the acute reaction; send people with a severe reaction to hospital.
- Document details as above.
- Provide person with information.
6.8 Refer to a specialist drug allergy service if they have
- A suspected anaphylactic reaction.
- A severe non immediate cutaneous reaction, for example, Stevens-Johnson Syndrome.
- This should be via primary care and be communicated in any discharge letter.
Document control
- Version: 2.
- Unique reference number: 560.
- Date ratified: 3 October 2023.
- Ratified by: Clinical policy review and approval group.
- Name of originator: Senior pharmacist.
- Name of responsible individual: Executive medical director and medicines management committee.
- Date issued: 27 October 2023.
- Review date: 31 October 2026.
- Target audience: Trust wide.
- Description of changes: Document review.
Page last reviewed: April 24, 2024
Next review due: April 24, 2025