Hospital Pharmacy Standard Operating Procedure

Description

Medicines Reconciliation from Hospital Outpatient Documentation by Medicines Management Team in Primary Care This standard operating procedure should only be followed by pharmacy technicians and pharmacists who have completed relevant training on medicines reconciliation in primary care. The medicine policies and procedures for the specific GP practice should also be read and followed. Professional judgement should be used at all times and further advice should be sought when necessary (e.g. if an action is not within area of competence). Open patient record and check that the name, address and date of birth correspond with the hospital correspondence. Review the current medication on the patient record and check whether any recommended medication changes have already been actioned. If any medicines changes have already been actioned on the system by a non-clinical member of staff then a clinical check of the appropriateness of the medication must be undertaken by a suitably trained healthcare professional. Paediatric medication should not be added by non-clinical staff. Start new consultation in the patient clinical record/computer notes as per practice procedures. Add read code 8B318 (Medication Reconciliation). Record the source of information including type of hospital documentation, speciality and date of clinic as per practice procedure (g. ENT clinic letter 23/12/18). Review the current medication list and consider whether it is appropriate to action the medication changes advised in the hospital correspondence. Consider therapeutic need, medicine/medicine interactions, medicine/disease interactions, allergies, polypharmacy, compliance, therapeutic duplications, dosage, medical history, investigations, test results, local formulary etc). Judgements should only be made within area of competence and appropriate advice should be sought where necessary (e.g. GP or suitably trained non-medical prescriber). Pharmacy technicians should always have any medication added to the repeat clinically checked and reviewed by an appropriate clinician (e.g. GP, suitably trained non-medical prescriber or clinical pharmacist). Compare the current medication list and the hospital outpatient documentation. For each medication reconcile as follows: Check if the dose of any current medication has changed and amend if appropriate. If known, record the reason for dose change in the patient record. Enter read code 8B3A2 (medication decreased) or 8B3A2 (medication increased). Review whether any new medication started should be added as an acute or repeat medication as per practice procedures. Certain medicines started in secondary care may not be suitable for repeat prescribing in primary care and an acute prescription may be more suitable (e.g. post-operative short term painkillers, newly started short term hypnotics, acute courses of medication such as antibiotics, short term ‘when required’ medication). If any medicines have been stopped by secondary care, remove the item from the repeat and record the reason for discontinuation in the patient record (e.g. stopped by hospital due to/as…..). Enter the read code 8B3R (drug therapy discontinued). Check the correspondence for any information on new allergies or adverse drug reactions. Add any medicines classified as RED on the BCUHB BRAG list as ’hospital supply – do not issue’ as per practice procedure. Ensure arrangements have been made for hospital supply of the medicine. Check that any medicines which are classified as AMBER with shared care on the BCUHB BRAG list have a shared care agreement scanned into the records and liaise with secondary care as necessary to clarify any issues. Add an indication (if possible/known) for any ‘when required’ medicines (e.g. painkillers and laxatives). Certain ‘when required’ or seasonal products such as painkillers, laxatives, hayfever treatments which are on the repeat prescription may not be present on the hospital outpatient correspondence. Providing there are no duplications or interactions with new medication added these items may remain on repeat. However, a review of ongoing therapeutic need should be undertaken. Review any prescribing alerts (e.g. interactions, disease warnings, therapeutic duplications, ScriptswitchÒ). Decisions should only be made within area of competence and appropriate advice should be sought where necessary (e.g. from GP or suitably trained non-medical prescriber). The reason for overriding any warnings should be noted in the consultation where appropriate. Check that the directions entered for each medication is clear and correct as per practice policy (including dose, frequency and duration if relevant). Check that the medicine has an appropriate quantity on repeat which is synchronised with the current repeat ordering frequency (e.g. 28 days). Check that an appropriate number of repeat re-issues has been authorised (e.g. if practice policy is to re-authorise repeat medication according to number of issues) or that there is an appropriate medication review date (e.g. if practice procedure is to re-authorise repeat medication according to medication review date). Follow practice procedures as appropriate. Action any monitoring, tests, patient follow-up or referrals that are required in line with practice procedures. If there are any doubts or uncertainty about the advice in the hospital documentation, the author of the documentation/prescriber/consultant secretary or hospital pharmacy should be contacted as appropriate. If unable to clarify any information, refer to a GP or suitably trained non-medical prescriber as appropriate before making any alterations. Judgements should only be made within area of competence and appropriate advice should be sought where necessary. Contact the patient to discuss any issues as necessary. Double check any changes made to the medication against the hospital documentation. It is good practice for this to be double checked by a second person, especially for complex regimens. Follow practice procedures as appropriate. Save and close consultation. Issue a repeat prescription if necessary for any new/altered items. Attach the printed repeat prescription to the hospital documentation and leave for a GP/non-medical prescriber to sign as per practice procedure. Ensure all sources of information/documentation are scanned in to the patient record as per practice procedures.