May 21, 2018
Taking a Medication History
In 2015 the National Institute of Health and Care Excellence (NICE) issued updated guidance aimed at optimising the use of medicines. There is a section on medicines-related communication systems when patients move from one care setting to another. This covers both the transfer of a patient within an organisation and the transfer between different organisations including admission to and discharge from hospital, whether from home or from a different healthcare setting. The current care provider must share complete and accurate information about the person’s medicines with the new care provider. The new care provider must ensure this information is received and accurately documented and acted on appropriately. Ideally this information exchange should take place within 24 hours of transfer.
The Institute for Healthcare Improvement defines medicines reconciliation as:
- Identifying an accurate list of a person’s current medicines and comparing them with the current list in use
- Recognising and resolving any discrepancies
- Accurately documenting any changes
This process should result in the accurate communication of a complete list of the patient’s medicines, including any over-the-counter or complimentary medicines.