• Always document Prior To Admission medications in the correct section, not free text.

• Reconcile medications at every transition—admission, transfer, discharge.

• Document rationale for all medication changes.

• Use Epic’s smart tools, navigators, and templates to reduce manual entry and errors.

This is a controlled document. If you are using a printed copy, check it against the guidelines site to ensure you are using the latest edition. Print copies must be destroyed after use.

• The following guidelines have been agreed by the Chief Clinical Information Officer, Deputy Chief Pharmacist and the Corporate Lead for Medication Safety

• This guideline outlines the principles of safe inpatient prescribing, including appropriate use of digital workflows to carry out reconciliation of home medications, placing inpatient orders and discharge medication orders

• A medication order in the digital sense, within Epic, is an electronic prescription

• Clinicians using the electronic prescribing system with our electronic patient record Epic, can do this with increased safety when the correct workspaces are used for documenting information relating to patient medications

a. Documenting Prior to Admission (PTA, home) Medications

• Use the Admission Navigator in Epic to document PTA medications. This ensures safe prescribing and accurate discharge summaries.

• Sources for PTA Medications include GP records via Connected Care, patient/family/carer input, and external records (Care Everywhere).

• Home medications should not be documented as free text in notes—use the dedicated section to ensure integration into reconciliation and discharge workflows.

• Include all prescribed, over-the-counter, complementary, and private medications. For private prescriptions, add a note in the PTA list.

• The admitting doctor or Advanced Clinical Practitioner (ACP) is responsible for documenting home medications during clerking.

• The Pharmacy team aims to check most PTA lists but is not always not able to do so, especially during short admissions. If the PTA list is marked as Pharmacy Complete for the admission, the medical team does not need to review further.

• The PTA list may have been already populated by the patient via MyFrimleyHealth Record and from previous admissions or encounters and may be out of date, so it must be updated with the latest information available. Remove any medications the patient is not taking by clicking the red cross and update any changes to dosages/frequencies.

• Include all information including dose, frequency and route in PTA medications. This makes it quicker and easier to prescribe as an inpatient during Admission Medicines Reconciliation.

• Document last doses taken. This helps scheduling of next doses and is important for drugs that need to be held before procedures such as anticoagulants.

• When the PTA medications are documented, set the med list status as and click Mark as Reviewed to confirm the status of the PTA medications list. This completes the digital sign off that the medication reconciliation is complete by your profession.

b. Admission Medication Reconciliation

• Reconcile all home medications when admitting patients. This must be completed within 24 hours of admission (NICE 2016) and is a Trust-wide safety priority. This will normally be done during medical clerking using the Admission Navigator.

• In the Admission Orders section:

- Review current orders (e.g., ED medications).

- Continue, discontinue, or modify as appropriate.

- Any deliberate changes to Home Medications need to be documented in notes and ‘Hospital Course’ so that pharmacists and GPs are informed of the reason for the changes

- Order home medications for inpatient use. Do this from the Admission Orders section of the Admission Navigator by clicking the green plus sign to continue as an inpatient.

- Choose “Order and Hold” if being stopped temporarily.

- Choose “Replace” if they are to be substituted for another med.

- Use “Don’t Order” for medications to be stopped and document rationale in the Hospital Course.

- Admissions medicines reconciliation is not complete until every PTA medications has been marked with a decision. The Admission Checklist in the Sidebar summary will confirm “Admission Med Rec Complete” when this is done.

c. Our Practice Advisories (OPAs)

• Review OPAs for VTE risk, allergies, and other critical results during admission.

• VTE risk assessment and appropriate prophylaxis prescribing is mandatory.

• Medication reconciliation must occur at every transfer of care (admission, intra-hospital transfer, discharge).

• For non-formulary or unavailable medications:

- Use the “Unable to Find” placeholder for free-text prescriptions with full details for pharmacy and nursing.

• Use the Discharge Navigator to reconcile all home and inpatient medications.

- Review both original home medications and inpatient orders side-by-side.

- Decide which home medications to resume and which inpatient medications to prescribe after discharge.

- Actions include continue, discontinue, modify, or add new prescriptions.

• Document rationale for all medication changes in the “Med Change Rationale” section—this appears in the GP discharge letter.

• Ensure discharge summaries and After Visit Summaries (AVS) clearly communicate all medication changes.

• For day cases, use the “quick discharge” navigator. In this workflow PTA medications are not reviewed and reconciled and only TTO medications need to be ordered.

- Minimum 14 days’ supply for new medications, 7 days for Monitored Dosage System (MDS) with arrangements for further supply.

• Medicines reconciliation is a Trust quality priority with board-level oversight and monthly reporting.

• Increase use of admission and discharge navigators to improve reconciliation and order generation.

• Report near misses, documentation and medicine administration errors to improve feedback and safety using the InPhase incident reporting system.

• Always document PTA medications in the correct section, not free text.

• Reconcile medications at every transition—admission, transfer, discharge.

• Document rationale for all medication changes.

• Use Epic’s smart tools, navigators, and templates to reduce manual entry and errors.