Medication Reconciliation – On Admission Definitions by lindayy

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Medication Reconciliation – On Admission Definitions

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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 consumer’s 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
                                 U




          Medication                 • Document the medication information obtained on admission on the
            History                    Medication History & Reconciliation on Admission Form (MH&R Form)
           Interview                 • 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                            P   P




                                                of the form
                                            o Any other relevant information

                                 Confirming the History
                                    • Confirm the medication history obtained on admission with the patient and
        Confirmation                    where appropriate with their community health care provider (i.e. for high
           of the                       risk patients)
         Medication                 • All histories are to be confirmed with a second source if possible using the
          History                       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 Dr’s plan for each of the medications listed. Additional notes on
                                                                                                                   nd
                                        reason for Dr’s plan can be placed in the “Other Information” box on the 2                              P   P




                                        page of the form
                                    • Sign and identify yourself as the person obtaining and recording the
                                        information in the “Signature and Profession” column

                                 Reconciling
         Reconciling                • Check that each medication listed matches the medications prescribed on
           of the                       the medication chart taking into consideration the Dr’s plan
         Medication                 • Tick the reconcile column once the medication has been checked and
                                        matches the plan (Do not mark this column until any discrepancy has been
           History
                                        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:                  Insert, Addressee's Fax No.                                  FROM:                 Fax:           Insert, Sender’s Fax No
                    Name:                   Insert, Addressee's Name                                                         Phone:           Insert, Sender's Tel. No.
              Organisation:                 Insert, Addressee's                                                               Name:           Insert, Sender's Name
                                            Organisation Title
                              Date:         Insert, Date                                                                 Position:            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.     Review the attached list of medications
       2.     Tick confirmation column if medication correct
       3.     Document any additions or amendments on the list
       4.     Place any comments in the section below
       5.     Fax back this cover sheet and confirmed list or phone
       6.     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.

______________________________                                                   _______________________________                                              ________________
    (Client’s Name)                                                                        (Client’s 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.
                                                                                                                                                                                                                                          (Affix patient identification label here)

                                                                                                                                                                                                        URN:

                                                                       MEDICATION HISTORY &                                                                                                             Family name:
                                                                    RECONCILIATION ON ADMISSION                                                                                                         Given names:

                                                                                                                                                                                                        Date of birth:                                                                                         Sex:                   M                F
                                                                    Facility:..............................................................................................................

                                                                    CHECKLIST                                   Patient’s GP: .................................................................................................................. Community Pharmacist: ........................................................................................

                                                                          Prescription medicines                                                                                                                     Complementary medicines (e.g. vitamins, herbal or natural therapies)
                                                                          Sleeping tablets                                                                                                                           Topical Medications (e.g. creams, ointments, lotions, patches)
                                                                          Inhalers, puffers, sprays, sublingual tablets                                                                                              Inserted medications (e.g. nose/ear/eye drops, pessaries,
                                                                          Oral contraceptives, hormone replacement therapy                                                                                           suppositories)
                                                                          Over-the-counter medications                                                                                                               Injected medications
                                                                          Analgesics                                                                                                                                 Recently completed courses of medication
                                                                          Gastrointestinal drugs (for reflux, heartburn, constipation,                                                                                Other people’s medication
                                                                          diarrhoea)                                                                                                                                 Social and recreational drugs

                                                                        ALLERGIES & ADVERSE DRUG REACTIONS (ADR)                                                                                     MEDICATION LIST LEGEND
                                                                        Nil known     Unknown (tick appropriate box or complete details below)
                                                                         Drug (or other)               Reaction/Date                  Initials                                                       Source of                                    Professions:                                            Discharge Info:
                                                                                                                                                                                                     information:                                 RN: Nurse                                               OM: Own Med
                                                                                                                                                                                                     GP: General                                  MO: Medical Officer                                      PBS: PBS Item / Quantity
                                                                                                                                                                                                           Practitioner                           HP: Hospital Pharmacist                                 A:   Authority Script
                                                                                                                                                                                                     CP: Community                                RIPEN: Rural and Isolated                               H:   Hospital Item Only
                                                                                                                                                                                                           Pharmacist                                    Practice Endorsed                                S8: Controlled Drug
DO NOT WRITE IN THIS BINDING MARGIN




                                                                                                                                                                                                     P:    Patient                                       Nurse                                            Doctor’s Plan:
                                                                                                                                                                                                     C:    Carer                                                                                          :   Continue
                                                                                                                                                                                                     NH: Nursing Home                                                                                     w:   Withhold
                                                                                                                                                                                                     OM: Own meds                                                                                         :   Cease
                                                                                                                                                                                                     CN: Community                                                                                        ▲: Change
                                                                   Sign: ................................. Print: ............................. Date:                                                      Nurse

                                                                    Date of admission: .............................................................                                              MEDICATION LIST
                                                                                                                                                                                                                How long              Indication              Source                     Signature                            Date
                                                                                                       Medication                                                                                                                                                             Dr’s                          Recon-                    Discharge
                                                                     Date                                                                                                          Dose       Frequency         or when              (confirm with             of infor-                  & Profes-                          confirmed
                                                                                        Generic name (Trade name) / Form / Strength                                                                              started                                                      Plan                           cile                        Info
                                                                                                                                                                                                                                        patient)              mation                        sion                           and Source




                                                                                                                                                                                                                                                                                                                                                                  MEDICATION HISTORY AND RECONCILIATION ON ADMISSION
                                                                                                                                                                                                                                                                                                                          O N
                                                                                                                                                                                                                                                                                           A TI
                                                                                                                                                                                                                                                     S TR
                                                                                                                                                                                                                                 N I
                                                                                                                                                                                                                          I
                                                                                                                                                                                                  D M
                                                                                                                                                                                              A
                                                                                                                                                    O R
                                                                                                                                      F
                                      SW 013 Pilot v1.00 06/2005




                                                                                                O T
                                                                                 N
                                                                                                                                                 KEEP WITH ACTIVE MEDICATION CHART - DO NOT REMOVE
Source of information:                                           Discharge Info:
GP: General Practitioner                                         OM: Own Med                                                                                               (Affix patient identification label here)
CP: Community Pharmacist
P:     Patient                                                   PBS: PBS Item / Quantity
C:     Carer                                                     A:    Authority Script                                                  URN:
NH: Nursing Home                                                 H:    Hospital Item Only
OM: Own meds
CN: Community Nurse
                                                                 S8:   Controlled Drug                                                   Family name:
Professions:                                                     Doctor’s Plan:
RN: Nurse                                                        :    Continue                                                          Given names:
MO: Medical Officer                                               w:    Withhold
HP: Hospital Pharmacist
RIPEN: Rural and Isolated Prac-                                  :    Cease                                                             Date of birth:                                                                                               Sex:                     M                 F
       tice Endorsed Nurse                                       ▲:    Change

                                                                                                                             MEDICATION LIST
                                                                                                                                                  How long            Indication                 Source                       Signature                               Date
                                   Medication                                                                                                                                                                     Dr’s                             Recon-                     Discharge
  Date                                                                                                  Dose               Frequency              or when            (confirm with                of infor-                    & Profes-                             confirmed
                    Generic name (Trade name) / Form / Strength                                                                                    started                                                        Plan                              cile                         Info
                                                                                                                                                                        patient)                 mation                          sion                              and Source




                                                                                                                                                                                                                                                       TI ON
                                                                                                                                                                                                           T RA
                                                                                                                                                                     N IS
                                                                                                                                D MI
               A
            OR




                                                                                                                                                                                                                                                                                                             DO NOT WRITE IN THIS BINDING MARGIN
        T F
     NO
Are patient’s own medications available?                                                                                                                      Checklist Completed:
  Yes, all           Yes, some          No
                                                                                                                                                               Signature: ........................................................................................ Date: .................................
        Comments (where are they?): .........................................................................................

OTHER INFORMATION - RECENTLY CEASED OR ALTERED MEDICATIONS - COMPLIANCE
         Assess compliance by asking: 1. “People often have difficulty taking their pills for one reason or another.. have you had any difficulty taking your pills?”
                                      2. “About how often would you say you miss taking your medicines?”




MEDICATION RISK ASSESSMENT
Level of Independence                                                                                                                                 Patient Assessment
      Looks after own medication                                                                                                                      Can read                                                                Yes                     No
      Carer looks after medication                                                                                                                    Can see/read labels                                                     Yes                     No
      Uses dose administration device i.e. spacers, inhaler devices                                                                                   Can understand English                                                  Yes                     No

      Uses administration aid (specify): ..................................................................................                             If no, language spoken is: ......................................................................................................
      Uses medication record                                                                                                                          Can open bottles                          Yes                         No
      Fully dependent on others (e.g. lives in Nursing Home)                                                                                          Can measure liquids                       Yes                         No                        Not an issue

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

                                                                       KEEP WITH ACTIVE MEDICATION CHART - DO NOT REMOVE
                   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 patient’s medication
    use on admission
 3. The medication information obtained on admission is to be confirmed 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 filed 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                       j                  j
   document all current
   medications on admission
                                                      k
   (include indication and
   duration of therapy)
3. Record the source of
   information:
   use code eg ‘P’ for patient (see
   legend)                                                                                               r                   s
4. Record the Dr’s plan: use code
   eg. ✓ for continue                        k                   m
                                                                l nop q
5. Sign and record your profession                                                            11
   using code (person recording
   history)
6. Reconcile i.e. tick that each
   medication has been checked
   against the active medication                                                                         12
   chart and reflects the Dr’s plan
7. Record date medication history
   confirmed and state source
   using code                          9. Record if own medications were brought into hospital
8. Pharmacist to record any            10. Sign and date that checklist (step 2) has been completed
   discharge information if            11. Record compliance issues, any recently ceased or altered medications and any
   necessary                               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
                                                                Patient                   Green – MO’s, Pharmacists , RIPEN’s
         MEDICATION                                           Presents to                 Tan - MO’s
                                                              ED or Ward
          HISTORY                                                                         Purple – Pharmacists , RIPEN’s


                                              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 the previous
                                                       Is the patient a high risk                      Healthcare professional /s
                                                                                                 YES
                                                     patient ? (refer to guidelines )                  +/- carer (Confirmation +
           Confirm with any
                                                                                                          Medication Liaison )
              2 nd source
            (Confirmation )




                                                         Any discrepancies or
                                                           queries between
                                                              sources ?
                    Document in                                                                            Obtain clarification
                  “Date confirmed                                                                         from patient or carer
                    and source”                                                                             and document on
                  column on form                   NO                                   YES                       form



   RECONCILIATION

           1. MO to decide plan for each                                                                   Has the Dr’s plan
                    medication                                                YES                          been recorded ?
         2. Document this plan in the “Dr’s
          Plan” column on the form using
                the supplied legend
                                                                                                                 NO
                                                                Where?
                                                                                                          Liaise with Medical
                                                                                                              Officer and
            MO to write medications on                                                                    document on form
            to the Medication Chart in
             accordance with the plan
                                                              Recorded in
                                                              the medical               On form
                                                                 notes

          1. MO to check each medication
           listed on form has a plan which                                     Transfer to the
         coincides with the Medication Chart                                     “Dr’s plan”
        2. MO to tick the “Reconcile” column                                   column on the
                      on the form                                                   form

                                                                                                        Check each medication
                                                        Medication History and                          listed has a plan which
                                                     Reconciliation on Admission                           coincides with the
                                                     form kept at end of bed with                      medication chart and tick
                                                         the Medication Chart                          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.

								
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