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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.
Medication
History
Interview
Confirmation
of the
Medication
History
Reconciling
of the
Medication
History
Reconciling
Check that each medication listed matches the medications prescribed on
the medication chart taking into consideration the Drs plan
Tick the reconcile column once the medication has been checked and
matches the plan (Do not mark this column until any discrepancy has been
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
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:
Name:
Organisation:
Date:
FROM:
Fax:
Phone:
Name:
Position:
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.
2.
3.
4.
5.
6.
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.
______________________________
(Clients Name)
_______________________________
(Clients 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.
Given names:
Date of birth:
Facility:..............................................................................................................
CHECKLIST
Family name:
Medication
Generic name (Trade name) / Form / Strength
T
O
R
O
Professions:
RN: Nurse
MO: Medical Ofcer
HP: Hospital Pharmacist
RIPEN: Rural and Isolated
Practice Endorsed
Nurse
Discharge Info:
OM: Own Med
PBS: PBS Item / Quantity
A:
Authority Script
H:
Hospital Item Only
S8: Controlled Drug
Doctors Plan:
:
Continue
w:
Withhold
:
Cease
: Change
MEDICATION LIST
Dose
Frequency
How long
or when
started
M
D
Indication
(conrm with
patient)
I
N
Source
of information
Drs
Plan
R
T
S
Signature
& Profession
Reconcile
I
T
A
Date
Discharge
conrmed
Info
and Source
N
O
Nil known
Unknown (tick appropriate box or complete details below)
Drug (or other)
Reaction/Date
Initials
Prescription medicines
Sleeping tablets
Inhalers, puffers, sprays, sublingual tablets
Oral contraceptives, hormone replacement therapy
Over-the-counter medications
Analgesics
Gastrointestinal drugs (for reux, heartburn, constipation,
diarrhoea)
Date
Sex:
Source of information:
GP: General Practitioner
CP: Community Pharmacist
P:
Patient
C:
Carer
NH: Nursing Home
OM: Own meds
CN: Community Nurse
Professions:
RN: Nurse
MO: Medical Ofcer
HP: Hospital Pharmacist
RIPEN: Rural and Isolated Practice Endorsed Nurse
Discharge Info:
OM: Own Med
PBS: PBS Item / Quantity
A:
Authority Script
H:
Hospital Item Only
S8:
Controlled Drug
Doctors Plan:
:
Continue
w:
Withhold
:
Cease
:
Change
Sex:
MEDICATION LIST
Date
Medication
Generic name (Trade name) / Form / Strength
Dose
Frequency
I
M
D
Source
of information
S
I
N
Drs
Plan
Signature
& Profession
Reconcile
A
R
T
Date
Discharge
conrmed
Info
and Source
N
O
TI
Checklist Completed:
Signature: ........................................................................................ Date: .................................
Patient Assessment
Can read
Can see/read labels
Can understand English
Yes
Yes
Yes
No
No
No
A
R
O
F
T
NO
Indication
(conrm with
patient)
How long
or when
started
PH:
j
k
r
k
lmnop q
11
12
Patient
Presents to
ED or Ward
MEDICATION
HISTORY
YES
Any discrepancies or
queries between
sources ?
Document in
Date confirmed
and source
column on form
NO
YES
Obtain clarification
from patient or carer
and document on
form
RECONCILIATION
1. MO to decide plan for each
medication
2. Document this plan in the Drs
Plan column on the form using
the supplied legend
YES
NO
Where?
Liaise with Medical
Officer and
document on form
MO to write medications on
to the Medication Chart in
accordance with the plan
Recorded in
the medical
notes
1. MO to check each medication
listed on form has a plan which
coincides with the Medication Chart
2. MO to tick the Reconcile column
on the form
On form
Transfer to the
Drs plan
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.