Building the medicines picture: history, reconciliation and transitions

MED2 — Building the medicines picture: history, reconciliation and transitions

• Distinguish a medicines list from a verified medicines history.
• Use more than one information source when reconciliation is clinically important.
• Identify common discrepancies at admission, transfer and discharge.
• Explore adherence and access without assuming non-compliance.
• Create a clear medicines plan that can be understood by the next team and the patient.

A medication record may show what was prescribed, not what the patient is actually taking. A safe medicines history asks what is prescribed, what was recently stopped, what the patient takes regularly, what is taken only when needed, what has been omitted because of side effects or access problems, and what is obtained over the counter, online or from another prescriber. Herbal and complementary products may also matter. The aim is to reconstruct the patient’s real medicines exposure.

No single source is perfectly reliable. Patient or carer report, repeat-prescribing records, community pharmacy data, hospital discharge summaries, care-home administration records and specialist clinic letters may disagree. Where the medicine has high consequence if omitted, duplicated or continued incorrectly, discrepancies should be actively resolved. The source used and unresolved uncertainty should be recorded rather than hidden behind a copied list.

Transitions create predictable errors: omission of long-term treatment, continuation of a medicine intended to be temporary, duplication after brand or formulation changes, restarting a medicine deliberately stopped, wrong frequency, and failure to adjust for new renal function. Frailty, cognitive impairment, multiple prescribers and frequent admissions increase complexity. Reconciliation should therefore be prioritised according to clinical risk rather than treated as a uniform clerical task.

A safe discharge medicines plan explains what has changed and why. It should identify medicines started, stopped, withheld, dose-adjusted or changed in formulation; specify intended duration where relevant; and state what monitoring is needed and who should act on it. A discharge list that merely reproduces the final inpatient chart can export ambiguity into primary care, community hospitals or care homes.

When a patient does not take treatment as prescribed, the reason matters. Causes include adverse effects, swallowing difficulty, cognition, beliefs, cost or access, packaging, regimen complexity, misunderstanding, fear of dependency and competing daily priorities. The response should be curious and non-judgemental. Escalating doses without recognising non-adherence can produce toxicity if the patient later begins taking the intended regimen.

Particular attention is needed for insulin, anticoagulants, anticonvulsants, Parkinson’s medicines, corticosteroids, opioids, benzodiazepines, lithium, methotrexate and other medicines where omission, duplication or dosing error can have major consequences. The course does not provide static dose tables; learners should verify medicine-specific advice in current authoritative references and local systems.

A usable reconciliation record

Good documentation distinguishes confirmed facts from assumptions. It should make visible the source of the medicines history, important discrepancies, actions taken, outstanding queries, patient understanding and the next responsible clinician. This improves continuity because the next team can see the reasoning rather than reverse-engineering it from a list.

Sources for this module

• NICE NG5: Medicines optimisation
• AWTTC/AWMSG current medicines optimisation and community medicines-management resources
• GMC prescribing guidance

Educational note: medicine-specific doses, thresholds and rapidly changing regulatory requirements should be checked against current authoritative guidance at the point of care.