An up to date and accurate list of the medications taken by a patient prior to admission is essential to facilitate safe prescribing and continuity of medication management throughout the episode of care.

The patient's best possible medication history (BPMH) is recorded on admission to Ballarat Health Services including when accepting transfer of care from another facility. The electronic version of the BPMH form is then made available in the patient's electronic medical record (EMR) and a printed copy is placed with the National Standard Medication Chart throughout the episode of care.

ACSQHC: Australian Commission on Safety and Quality in Healthcare

BPMH: Best Possible Medication History. A medication history is a record of all the medicines actually taken by the patient in the period before admission or presentation for the episode of care and includes information about previous adverse drug reactions (ADRs), adverse medicines events and allergies and recently ceased or changed medicines. The record is confirmed using a number of different sources. Obtaining a best possible medication history involves:

• reviewing background information

• conducting a patient/carer medication history interview.

eForm: an online form generated via BOSSnet that replaces the need for paper documentation.

Medication: Refers collectively to medications, medicines, drugs or therapeutic agents administered by any route.

Medication chart: A BHS approved form where medications are prescribed, administered or dispensed from e.g. National Standard medication chart (NSMC) - all versions, Clozapine chart, IV fluids chart, Subcutaneous Insulin chart

Medication reconciliation: A formal process intended to prevent medication errors and medicines-related problems at transition points in patient care (admission, discharge and transfer). The process involves comparing a patients best possible medication history with the current medication orders in the context of the patient's current condition, their treatment plan and medication management plan in order to identify if any unintended changes to the patient's medications have been made. Medication reconciliation also involves addressing and resolving the identified discrepancies and/or medication-related problems and documenting information regarding resolutions and/or recommendations made.

Medication review: A critical review of all medications prescribed along with test results and other clinical information to ensure each medications appropriateness, evaluate patient's response and identify and manage any actual or potential medication-related issues.

Patient: For the purpose of this policy, patient shall refer to patient/client/resident

Patients Own Medicines: Any medication that a patient has brought with them to hospital that has been dispensed to or purchased by them prior to admission.

The electronic Best Possible Medication History and Reconciliation form MR 701.1 should be completed on BOSSnet for every patient within 24 hours of admission to Ballarat Health Services. Ideally the BPMH is undertaken prior to prescribing or administering any medication, or prior to performing any procedure that may interact with a patient's medications. Once completed the form is to be printed and filed with the medication chart. If access to BOSSnet is unavailable, the BPMH can be completed on the paper based form MR 701.1.

A medical officer or pharmacist can complete the BPMH form, however evidence suggests this task is poorly done by those not focused on medication management and that pharmacists obtain more accurate medication histories that other health professionals. (Ref: SHPA Committee of Specialty Practice in Clinical Pharmacy (2013). Standards of Practice for Clinical Pharmacy Services.  43:2 (supp)

A BPMH must be completed for each patient presenting for care at BHS as soon as practical and ideally within 24 hours of admission.

A BPMH is not required for newborns who have not been discharged home or transferred outside of BHS or any patient with a length of stay on acute inpatient wards less than 24 hours.

The BPMH taken within the Emergency Department will reflect the type and acuity of care required. All patients who are admitted to an inpatient ward from the Emergency Department (including the Short Stay Unit) require a BPMH if length of stay exceeds 24 hours.

The BPMH will be recorded on the Best Possible Medication History and Reconciliation electronic form (MR 701.1) on BOSSnet, unless BOSSnet is unavailable. In this case, the paper-based form MR 701.1 will be completed and filed with the Medication Chart, unless specifically approved* by the Medication Safety and Therapeutics Committee (MSTC). The electronic form will ideally be completed once BOSSnet becomes available.

The BPMH for day stay patients (e.g. Medical Day Unit, Day Procedure Unit) may be recorded on BHS approved location specific forms. These forms must include a section for recording current medications and be available at the point of care. All patients who are subsequently admitted to inpatient wards from these areas require the BPMH to be completed on BOSSnet.

*MSTC has approved Mental Health, Adult Acute Unit (AAU) to store the BPMH form with the patient's progress notes, on the basis; of how medication charts are being stored, and that the progress notes are referred to when reviewing patients' medications.

The key steps in obtaining a best possible medication history are;

1. Review background information. Before conducting a medication history interview, review available patient-specific information using appropriate sources e.g. ward handover sheet, health records, transfer summaries, laboratory results, other health professionals. A combination of information sources may be used to compile and confirm the medication history. Assess whether the patient (or carer) will be able to provide a reliable medication history.

2. Conduct patient/carer medication history interview. Ideally, the medication history interview is conducted face-to-face with the patient or carer using a structured process and occurring within 24 hours of admission. The nature of the interview will depend on the patient and specific goals of the interview. Important components of a medication history interview include:

• Greeting the patient and/or carer and confirm the patients identity using three appropriate identifiers as per Patient Identification And Procedure Matching Policy -POL0036.

• Confirm and document an accurate and comprehensive allergy and adverse drug reaction history as per Adverse Drug Reactions (including Allergies) - Recording and Reporting Protocol - CPP0573

• Ask the patient/carer about the use of prescription and non-prescription medicines including complementary and alternative medicines. Obtain detailed information including the name, dose, frequency and duration of current therapy.

• Undertake a structured medication adherence assessment, including the patient's understanding and experience with taking their medications, the patient's attitude to current and previous medication therapy and the patient's ability to use medications as prescribed e.g. swallowing, literacy, dexterity difficulties.

1. Obtain patient's consent before requesting patient-specific information from other health professionals e.g. community pharmacy dispensing records, General Practitioner prescribing records.

2. Summarise the interview. Summarise important information and describe the expected plan for medication management. Allow the patient/carer to ask questions about their medicines during and at the conclusion of the interview.

3. Confirm accuracy of medication history. Determine if the medication history obtained from the patient/carer requires confirmation with alternative sources. This is important as a single source may not be current or accurate especially if the patient is not responsible for administration of their own medicines, if elements of the medication history are unknown or the medication history is complex, if the medication history includes high risk medicines or if a reliable history cannot be obtained from the patient/carer.

   It is recognised that it may not be possible for medical officers/pharmacists to verify the information provided with a second source immediately (e.g. after hours or when emergency treatment is required), but this verification must occur as soon as practicable. Two other reliable sources may be used if the patient/carer is unable to participate in the interview (e.g. community pharmacy dispensing record, my health record or GP). Ideally the patient/carer should be the primary source of information, although this may not be always possible.

4. Document medication history. The medication history should be accurately documented in the patient's medical record (electronic BPMH in BOSSnet) then printed and placed with the NSMC so that it is readily available to other healthcare providers involved in the care of the patient. The documentation should be updated when new information become available throughout the admission.

For detailed information regarding conducting a patient/carer medication history interview refer to the Society of Hospital Pharmacists of Australia (SHPA) Standards of Practice for Clinical Pharmacy Services available at: https://www.shpa.org.au/resources/standards-of-practice-for-clinical-pharmacy-services

BPMH minimum requirements (Medical Officers):

When a Medical Officer initiates the BPMH, either electronically or manually they are required to complete the information on tab 1 of the eform or the first page of the paper form as outlined below. (For detailed steps refer to the BOSSnet training page for more information about the electronically generated BPMH and the admission medication module.)

1. Confirm previous adverse drug reactions (including allergies), the nature of the reaction and an approximate time frame as to when the reaction occurred. These are to be completed in the Clinical Alert Manager (CAM) in BOSSnet. Allergies and alerts can be viewed in the BPMH Admission Medication, Allergy and ADRs tab.

2. A complete list of all medicines taken immediately prior to hospital admission (prescription, non-prescription (over-the-counter) and complementary medicines) including the following details:

• Generic name, strength and form

• Dose

• Route

• Frequency

• Indication

• Plan on admission (continue, cease, withheld, dose change).

• Initials

1. Changes to admission medication (ceased, withheld, dose change) including the reason to ensure ongoing continuity of care for the patient. e.g. medications withheld before surgery.

2. For intermittent dosing, confirm day(s) of the week and when the last dose was taken.

3. For females of childbearing age, confirm pregnancy or breastfeeding status.

4. Document weight and height if relevant to dosing.

5. Document all sources of information used to obtain and verify the information (such as General Practitioner, Community Pharmacist, Nursing Home, Own Medicines, Patient's Own Medication list, previous admission, My Health Record, SafeScript) where this is practical.

Once complete the printed eform or the paper form must be placed the patient's National Standard Medication Chart (NSMC).

 A comprehensive BPMH (usually performed by pharmacists):

The clinician performing the comprehensive BPMH can continue data entry on the BOSSnet eform or the paper form (when access to BOSSnet is not available) if the BPMH has been commenced by a medical officer. Updates and amendments to existing information can be made as necessary however all updates and amendments to existing information must be made electronically as the hard copy will not be scanned into medical record. The updated BPMH should be printed and replace the existing paper BPMH located with the NSMC if changes have been made to the medicines on admission section in all circumstances.

In addition to the minimum requirements for medical officers listed above, the following information should also be documented:

• An accurate and complete list of pre-admission medicines including prescription, non-prescription, recreational, complementary and alternative medicines and intermittently taken medicines. For each medication the following details should be documented: generic name, brand name if relevant, strength, dose form, dose, route, administration schedule, duration of therapy/when medicine started if relevant, indication (or perceived indication according to the patient if pending verification). If taking warfarin, the date and result of the last INR.

• Medicines that the patient has existing supplies of and medicines requiring supply on discharge.

• A description of who manages the patients medications.

• Location of the patient's own medications.

• Administration and/or adherence aids used prior to presentation (e.g. Webster Pak including who packs this, spacers etc).

• Indication for use of each medication.

• An assessment of patient adherence and risks including any issues such as literacy, hearing, vision, swallowing.

• Immunisation status.

• Contact information for GP, community pharmacy and residential aged care facility (if applicable).

• Details relating to current admission including presenting complaint, past medical history, admission weight and height, relevant biochemical data).

Once complete, the electronic BPMH must be printed and placed with the medication chart.

Medication Reconciliation:

Medication reconciliation should:

• Occur each time a patient is transferred from one episode of care to another and when new medication orders are written. Transfer may be within the organisation, on discharge or between providers of care.

• Include review of the previous medication orders alongside new orders and the care plan.

• Include review and resolution of discrepancies as they arise as well as available information to determine if discrepancies are intentional or non-intentional.

• Include communication with the prescriber to resolve medication-related problems.

1.   Medication reconciliation on admission or transfer

Medication reconciliation of patients' pre-admission or pre-transfer medications will be completed by a pharmacist as soon as practical after admission. Reconciliation is recorded on the Best Possible Medication History and Reconciliation Form (MR701.1) following the convention described in the ACSQHCs Medication Management Plan training guide.

For those areas without a clinical pharmacy service, a pharmacist referral can be generated for review of high risk patients (see Pharmacist - Referral Process For Inpatients- CPG0046). High risk patients may include those aged over 65 years old or on 5 or more regular medications.

2.   Medication reconciliation of new medication charts (including at intra-hospital & residential care transfer)

Each new medication chart transcribed requires medication reconciliation against the previous chart as soon as possible with any discrepancies clarified and rectified as soon as possible. This includes when medication charts are transcribed due to transfers to other BHS sites e.g. subacute wards and mental health). Reconciliation of the new chart undertaken by a pharmacist is recorded by signing the chart at the bottom annotating 'reconciled' and the date.

Charts for BHS residential care facilities should be reviewed by a pharmacist prior to transfer, and the pharmacist section signed and dated to indicate reconciliation has occurred.

3.   Medication reconciliation of discharge prescriptions involves comparing the medications on the discharge prescription to the medications that the patient was receiving as an inpatient and those that the patient was taking prior to admission and clarifying any discrepancies. This is performed prior to the patient leaving the hospital, and ideally by a pharmacist. The primary source of medications taken prior to admission is the Best Possible Medication History and Reconciliation Form (MR701.1).

Reconciliation on discharge is recorded with a signature in the relevant section of the discharge prescription ('reconciled by' section on the electronic prescription).

For each medication the discharge prescription is marked with;

• an up arrow if the medication dose has been increased

• a down arrow if the medication dose has been decreased

• new for any medications commenced in hospital and continued on discharge

• a list of any medications ceased during the admission

• any medications that are to be withheld and the required action for the patient prior to recommencement

• whether a medicines list or CMIs are required

Where a prescription is not reviewed by a pharmacist (e.g. after hours), the prescriber is responsible for undertaking medication reconciliation on discharge. This reconciliation is recorded in the discharge summary by indicating new medications and any medications that have changed.

Education

All clinicians involved in taking a BPMH must undertake the National Prescribing Service (NPS) module "Get it Right. Taking a Best Possible Medication History".

All pharmacists involved in conducting medication reconciliation must read the SHPA Standards of Practice for Clinical Pharmacy Services, Chapter 1: Medication Reconciliation

It is recommended that clinicians involved with medication review read the SHPA Standards of Practice for Clinical Pharmacy Services, Chapter 2: Assessment of Current Medication Management.

Evaluation of completion rates and quality of BPMH and Medication Reconciliation

To be audited monthly and the results reported to the Medication Safety and Therapeutics Governance Committee.

Medication Review:

Medication review is the process of conducting a clinical review of a patient's medication management which involves assessing all medications prescribed for clarity, validity, appropriateness and safety by taking into consideration the treatment plan, past medical history, laboratory results, observations and current clinical signs and symptoms to ensure medication therapy is optimised and identifying any actual or potential medication related issues. Any issues identified should be documented in the BPMH under the 'Medication action plan issues and actions' tab or in the patient's progress notes. Any urgent issues should be discussed and rectified with the medical team as soon as possible.

The clinical pharmacists will conduct a medication review for inpatients whilst in hospital. Priority will be given to high risk patients or those on high risk medications when resourcing restrictions occur. Completion of medication review will be indicated on the medication chart by a pharmacist initial in the pharmaceutical review box for the corresponding date. Refer to the SHPA Standards of Practice for Clinical Pharmacy Services, Chapter 2: Assessment of Current Medication Management and Chapter 3: Clinical Review, Therapeutic Drug Monitoring and Adverse Drug Reaction Management.