Medicine Reconciliation

MEDICINE RECONCILIATION

• Obtain and document on the medicines reconciliation form, an accurate medication list using at least two vital sources (if available). See 4.2 for further guidance
• Document a plan for each medicine on the medicines reconciliation form by completing the continue, withhold and stop boxes
• Prescribe medicines accurately onto the medicine chart
• Undertake medicines reconciliation on discharge and record this on the immediate discharge and prescription form.

• Clinical Pharmacy staff will check that medicines reconciliation is undertaken on admission, transfer and discharge and work with the multidisciplinary team to resolve any issues
• Assist with informal referrals from medical and nursing staff of more complex patients or where there is inadequate information to obtain an accurate medication history
• Dispense necessary medicines prescribed on the immediate discharge and prescription form
• There may be areas where pharmacy staff undertake medicines reconciliation on the admission document

• Highlight to medical staff if there are medicines that a patient normally takes at home that are not prescribed on the medicine kardex.
• Nurse practitioners will undertake medicines reconciliation on the admission document
• Check the correct medicine, dose and frequency are supplied to the patient from the immediate discharge and prescription form
• File the appropriate copy of the immediate discharge and prescription form in the patient’s notes.

• GP letter
• GP practice printout
• Medicine Administration Record Sheet (MAR)
• GP repeat slip
• Phone call with GP or practice pharmacist
• Community pharmacy
• Care home phone call
• Case notes / previous discharge prescription
• Community Nurse e.g. Community Psychiatric Nurse (CPN), District Nurse
• Day Hospitals
• Anticoagulation clinics
• Hospital pharmacy records e.g. anti-TNF medicines, psychiatric medicines
• Compliance chart / device
• Outpatient letters.

• Discuss each individual medicine, dose and frequency with the patient or carer (where possible)
• Use the patient’s own medicines (where possible) to verify the information on the electronic medication list to confirm the final list of medicines
• Check that the patient is not receiving medicines from sources other than GP e.g. antipsychotic clinics, infectious diseases unit, homecare companies, sexual health clinics, non-medical prescribing clinics, haematology clinics, community pharmacy over the counter medicines or herbal medicines.

• Parkinson’s Disease (PD) medicines – document the specific times of each PD medicine and the name of the different preparations
• Warfarin – record where INR is checked e.g. GP or anticoagulation clinic, usual dose at home, indication, target INR and length of therapy
• Steroids – record the length of course, whether it is long term maintenance, a short course or a reducing course
• Cytotoxics –need careful documentation
• For weekly / monthly treatments provide the day of the week or date of last dose
• Depot injections – record dose and frequency and date / site of last administration
• Methadone (for addictions management) – the dose must be confirmed with the GP or addictions team and the community pharmacy. Please note information relating to the patient being prescribed methadone may not be on the ECS.
• As required medicines – ensure it is specifically highlighted that these medicines are not regular and give clear directions of the intended frequency (e.g. analgesics and hypnotics)
• Hypnotics – often dose if changed frequently so always clarify specific dose is correct
• Insulin – ensure that correct dose, formulation and device are prescribed
• Clozapine – record date and time of last dose (do not prescribe if >48hours since last dose)
• Lithium – prescribe by brand, ensure correct formulation is prescribed
• This list is by no means exhaustive.

• Patient name and CHI number
• Sources of information used for the medication history
• Generic name of all current medicines unless brand specific e.g. Uniphyllin for theophylline, Priadel for lithium carbonate
• Short courses of medicines, for example steroids, antibiotics
• Dose and frequency
• Formulations / devices if applicable e.g. insulin devices, inhalers
• Non-prescription medicines including over the counter / herbal / homeopathic medicines
• Recently discontinued medicines if applicable
• Concordance issues that may be apparent
• Allergy status / adverse drug reactions and the nature of the reaction / allergy
• Signature of doctor, nurse or pharmacist documenting the medication history
• Time and date that medication history has been taken.

• Current medicine chart and previous medicine charts if necessary
• Medicine reconciliation form from admission
• ECS record.

• Complete a list of medication required at discharge with drug, dose and frequency and duration of treatment (if applicable)
• Detail the supply method for each medicine, in particular whether hospital pharmacy dispensing is required (if Patients Own Drugs not available)
• Document the reasons for stopping any medicines in hospital in the “Changes to Medication” section.
• Document any medication started during admission along with the indication in the “Changes to Medication” section
• Any medicine to be re-started following discharge (e.g. anti-platelet and anti-coagulants) must be clearly documented on the Immediate Discharge Prescription Form
• Any medicines which are to be monitored or reviewed must be documented clearly on the Immediate Discharge Prescription Form
• The Immediate Discharge Prescription Form must be clinically signed off by medical staff / non-medical prescriber.

• If discharge medication is required from pharmacy the Immediate Discharge Prescription Form must be sent to pharmacy for dispensing
• On return of dispensed medicines from pharmacy check against medicine chart and Immediate Discharge Prescription Form for accuracy
• Send a copy of Immediate Discharge Prescription Form to GP surgery and community pharmacy e.g. fax, email etc.
• Medicines are given to patient with appropriate counselling, especially where there have been changes to treatment.
• It must be documented on the Immediate Discharge and Prescription Form that the patient and / or carer has been counselled on their discharge medication
• Patients are given copy of the Immediate Discharge Prescription Form to hand into GP surgery.

• Lack of awareness of staff resulting in medicine not being supplied to patients on discharge.
• Staff not being able to access clinical policies, procedures and guidance documents to ensure the delivery of safe and effective care.

Dear Doctor

ACCESS TO THE EMERGENCY CARE SUMMARY BY SECONDARY CARE CLINICIANS

The purpose of this letter is to clarify rights of access to the Emergency Care Summary which contains important information about current medication prescribed by a patient’s General Practitioner.

The content of this letter has been agreed by the NHS Fife Information Governance Group and the National Emergency Care Summary Board. This letter provides information about:

• When it is appropriate to use presumed consent for access
• Access to the Emergency Care Summary in cases where the patient is unable to give informed consent.

Situations where presumed consent is acceptable

In emergency situations patients referred by the following routes will have already given consent to the Emergency Care Summary being accessed. These situations include:

• Referral directly from NHS 24
• Referral from the Primary Care Emergency Service
• Direct referrals from General Practitioners in emergency situations
• Where a recent referral from the General Practitioner is available in the Clinical Portal or Sci Store
• Where a patient is incapable of giving consent.

In summary, should a patient present in any of the ways described above the Emergency Care Summary can be accessed using presumed consent.

Access to the Emergency Care Summary where patients are unable to consent due to incapacity

Secondary care clinicians require access to the information contained in the Emergency Care Summary in both urgent situations and at times of transfer of responsibility through the inpatient care pathway. This can cause concerns for clinical staff when a patient is incapable of consenting. The following paragraphs outline the legal basis for consent in such situations:

During the first 24 hours of a patient’s admission access to the Emergency Care Summary, common law provides legal protection for such an intervention when a patient is incapable of consenting. Following advice from the Mental Welfare Commission the timeframe for such access is the first 24 hours of admission. The first 24 of a patient’s admission enables clinical staff:

• Consult with family members
• Consult with a Power of Attorney or Guardian where either of these exist
• Complete an Adults with Incapacity Act certificate in consultation with the family where this is required.

Access to the Emergency Care Summary beyond 24 hours where the patient remains incapable of giving informed consentmust be supported by the completion of an Adults with Incapacity Act Section 47 medical certificate. Such a certificate must be completed in consultation with the patient’s family.

With the above guidance it is clear that Clinicians in secondary care can and should be accessing the Emergency Care Summary.

A&E is the only place where patients are likely to attend hospital without having been referred by a General Practitioner, NHS 24 or the Primary Care Emergency Service. A&E staff will therefore require to continue asking a patient’s consent to access the Emergency Care Summary unless the patient is incapable of giving consent.

With best wishes.

Yours sincerely