Page 259 - Registrar Orientation Manual 2016

Medicines at admission and discharge
Many problems can arise from incorrect or poor charting of patients’ medications at admission. If incorrect medicines or doses are charted, this error can be easily replicated onto the discharge documents which can be interpreted by GPs and community pharmacists as intentional changes.
Medication history taking
Before prescribing a new patient’s medication:
1. Check for any allergies or adverse reactions.
2. Ask if the patient has a medication card or list of medicines with them.
3. Ask if the patient has their medicines with them. If so, visually inspect whenever possible and
verify dose, directions, product and for whom it was prescribed. Ask the patient what they are
actually taking.
4. Check if there is more than one medicine of the same class e.g. ACE inhibitors
5. Do they use non-oral medication like eye drops, ointments and inhalers? Patients sometimes
do not consider these as “medicines” and forget to tell you about them.
6. Does the patient use non-prescription medicines/items e.g. “over the counter” (OTC) NSAIDS, antihistamines, dietary supplements such as multivitamins, iron or herbal remedies
such as St John's Wort?
7. Consider adherence and how or whether the patient has been taking their medicines.
If you need to, contact the patient's GP or the patient's community pharmacy for clarification. Your ward pharmacist may also be able to help with checking medicine histories and can undertake medicines reconciliation (a formal process where currently prescribed medications are compared against the medication history).
Discharge
1. Involving pharmacists in the discharge process is a good way to ensure that the patient’s medication needs are met. Individualised medication cards may also be prepared for patients by the pharmacy team.
2. If you think a medication card would be beneficial for your patient, please alert your ward pharmacist. Cards will only be available on discharge if enough time has been allowed to complete this task. Otherwise cards will be posted to patients. Ideally, notify the ward pharmacist either the day before or several hours before discharge to avoid unnecessary pressure.
Writing discharge summaries
1. List all admission and discharge medications including name, dosage and frequency. Highlight any changes that have been made and why.
2. Review all medications on the medication chart as part of the discharge process – which ones are clinically indicated?
Writing discharge prescriptions
Community pharmacists do not have access to medical records, including discharge summaries, therefore write prescriptions for all discharge medicines, as this gives the community pharmacist a clear record of the entire intended regimen compared to the pre-admission regimen. If the patient already has some or all of these medicines at home, they can opt not to have them dispensed again at this time. Notes on prescriptions saying you have stopped drug X or it replaces drug Y are very helpful to the community pharmacist.