The diagnosis of the presenting condition plus co-morbidities Procedures carried out A list of all medicines prescribed for the patient on discharge form hospital (not just those dispensed at the time of discharge) Dose, frequency, formulation and of administration Medicines stopped and started, with reasons and dates Length of courses where appropriate (e.g. antibiotics) Details of variable dosage regimens e.g oral steroids, warfarin etc. allergies, intolerance and hypersensitivities and previous drug interactions Any additional patient information provided such as corticosteroid record cards, anticoagulant books etc. Details of any follow up appointments Adapted from Ongoing concerns missing data should be fed back to the tPCT and provider. Practices should participate in local audits. Any future monitoring required after the patient has been discharged should be undertaken and facilitated by the use of screen messages and reminders in the patients medical record The process should be double checked by another person from the list above The practice pharmacist should facilitate the above process The practice pharmacist should be involved in medicines reconciliation, especially where the patients are at high risk of harm from either their prescribed medication e.g. patients discharged on controlled drugs, NSAIDs or warfarin or diuretics or on two anti-platelets or when they are in a vulnerable patient group e.g. the elderly, those with complex co-morbidities and/or patients receiving polypharmacy. Wherever possible assistive technologies should be used to reduce patient harm e.g. patient safety messages on ScriptSwitch. Medicines reconciliation when patients are admitted to hospital Medicines reconciliation is equally important when patients are admitted to secondary care and practices should supply the following data as soon as possible after admission either by e-mail or to a secure fax
The diagnosis of the presenting condition plus co-morbidities Procedures carried out A list of all medicines prescribed for the patient on discharge form hospital (not just those dispensed at the time of discharge) Dose, frequency, formulation and of administration Medicines stopped and started, with reasons and dates Length of courses where appropriate (e.g. antibiotics) Details of variable dosage regimens e.g oral steroids, warfarin etc. allergies, intolerance and hypersensitivities and previous drug interactions Any additional patient information provided such as corticosteroid record cards, anticoagulant books etc. Details of any follow up appointments Adapted from Ongoing concerns missing data should be fed back to the tPCT and provider. Practices should participate in local audits. Any future monitoring required after the patient has been discharged should be undertaken and facilitated by the use of screen messages and reminders in the patients medical record The process should be double checked by another person from the list above The practice pharmacist should facilitate the above process The practice pharmacist should be involved in medicines reconciliation, especially where the patients are at high risk of harm from either their prescribed medication e.g. patients discharged on controlled drugs, NSAIDs or warfarin or diuretics or on two anti-platelets or when they are in a vulnerable patient group e.g. the elderly, those with complex co-morbidities and/or patients receiving polypharmacy. Wherever possible assistive technologies should be used to reduce patient harm e.g. patient safety messages on ScriptSwitch. Medicines reconciliation when patients are admitted to hospital Medicines reconciliation is equally important when patients are admitted to secondary care and practices should supply the following data as soon as possible after admission either by e-mail or to a secure fax
Repeat%20Prescription,%20Medication%20Review%20and%20Medicines%20Reconciliation%20PolicyMay%202010%20version%204.docx