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Documentation of patient information

A patient’s best possible medication history is recorded when commencing an episode of care. The best possible medication history, and information relating to medicine allergies and adverse drug reactions are available to clinicians.

Ideally, all patients will receive a comprehensive medicines assessment before any decision to prescribe a new medicine.

Best possible medication history and medication reconciliation

A key component of this assessment is obtaining a thorough medication history, or a BPMH.

The BPMH is a snapshot of the patient’s actual medication use, which may be different from information in their healthcare record, in the medicines list held by the patient, or provided by the patient’s general practitioner. It is vital that the patient (or carer) is actively involved and that the health service organisation has a formal, systematic process in place for obtaining a BPMH.1

A BPMH is essential for:

  • Ensuring continuity of medication management
  • Identifying medicine-related problems
  • Identifying potential medicine-related discrepancies
  • Informing the decision-making process
  • Optimising the use of medicines.

Medication histories are often incomplete, with medicines, strengths and doses missing, and over-the-counter and complementary medicines often omitted. Instituting a formal, systematic process for obtaining a BPMH on admission, and reconciling this history against the patient’s medicines ordered on the medication chart reduces medication errors on admission by more than 50%.2

Reconciling medicines at care transition points has been shown to reduce medication errors by 50–94%.3,4

If not corrected, the errors can persist throughout the episode of care and after discharge. Inaccurate medication histories can lead to discontinuation of therapy, recommencement of medicines that have been ceased, inappropriate orders and failure to identify a medicine-related problem.

For planned admissions, the BPMH can be documented as part of the pre-admission process.

The medication management plan (MMP) is designed to document the BPMH and record the key steps of medication reconciliation. It is suitable for use in both adult and paediatric settings. The ‘Medicines taken prior to presentation to hospital’ section on the front of the NIMC and the PBS HMC may also be used to record the BPMH. Health service organisations may also develop alternative hard-copy or electronic forms – for example, within an electronic medication management system.

The MMP or equivalent form should be stored with the current NIMC throughout the episode of care.

Medicine allergies and adverse drug reactions

Medicine allergies and ADRs can be classified as:

  • Known – those that have been previously experienced by the patient before their episode of care
  • New – those that are experienced by patients during their episode of care and have not been previously experienced or documented.

The administration of medicines to patients with a known medicine allergy or previous ADR can be prevented by having mechanisms in place for alerting clinicians who prescribe, dispense and administer medicines. Information on a patient’s known medicine allergies and ADRs can be collected on presentation to the health service organisation and recorded in the BPMH. Any new medicine allergies or ADRs should be recorded in the same place.

If there is any doubt about the nature of a medicine allergy (for example, an allergy to an antibiotic), there must be a process for clinicians to challenge and verify the diagnosis of true allergies. If a patient is not allergic, the patient’s history and healthcare record will need to be modified, including removal of allergy alerts.5

Medicine allergies and ADRs are included in the definition of an adverse drug event. If a patient is given a medicine that is contraindicated (that is, there is a known allergy or ADR), they are at risk of experiencing preventable harm.6

To minimise the risk of preventable harm from adverse drug events, it is critical to ensure that clinicians understand their responsibility to refer to a patient’s medicine allergy and ADR history before, or at the point of, decision-making when prescribing, dispensing or administering medicines.

All adverse drug events are expected to be reported using the organisation’s incident monitoring system. Clinicians are also expected to report new suspected ADRs to the Therapeutic Goods Administration (TGA) – this provides important information about possible adverse effects for the TGA’s safety monitoring program.


Medication reconciliation

Adverse drug reactions


  1. Institute for Safe Medication Practices Canada. Medication reconciliation. Toronto: ISMP Canada; 2017 [cited 2017 Oct 23].
  2. Kwan Y, Fernandes OA, Nagge JJ, Wong GG, Huh J-H, Hurn DA, et al. Pharmacist medication assessments in a surgical preadmission clinic. Arch Intern Med 2007;167:1034–40.
  3. Vira T, Colquhoun M, Etchells EE. Reconcilable differences: correcting medication errors at hospital admission and discharge. Qual Saf Health Care 2006;15(2):122–6.
  4. Rozich JD, Resar RK. Medication safety: one organization’s approach to the challenge. J Clin Out Manag 2001;8(10):27–34.
  5. Knezevic B, Sprigg D, Seet J, Trevenen M, Trubiano J, Smith W, et al. The revolving door: antibiotic allergy labelling in a tertiary care centre. Intern Med J 2016;46(11):1276–83.
  6. National Coordinating Council for Medication Error Reporting and Prevention (US). Contemporary view of medication-related harm: a new paradigm. NCC MERP; 2015 (accessed Sep 2017).
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