It is important to develop guidelines for documentation, for both electronic and paper charting, to ensure
that documentation is comprehensive and standardized between practitioners in the same setting.
Table 5: Recommendations for Medication Reconciliation (MedRec) Documentation
Medication management information (e.g., self-administration
or caregiver administration; use of
Name of person that completed the reconciled list
Sources of information used to complete BPMH
Name (generic name preferred)
Comments (additional information that would provide
value in establishing the patient's medication regimen
e.g., average number of as-needed medications
consumed in a week, prescribed medication use if
different than actual medication use)
Name of person that completed the BPMH
Figure 8 depicts how the elements listed may be incorporated into a MedRec form for paper charting and data fields on a screen for electronic charting.
Table 6: Tips for Documenting Medications
Tips for Documenting Medications
Record the generic medication name where possible (but remember that patients may be more familiar with the brand name).
Determine a convention for recording combination products, e.g., as two generic medication names with their respective dosages. e.g., Coversyl Plus = perindopril 4 mg and indapamide 1.25 mg or by brand name only.
Record how the patient is actually taking the medication. If actual use differs from how the medication was
prescribed then also record the original intent of the prescriber (i.e., prescribed use).
For liquid or injectable medications - record both the concentration and the total number of mg/mcg/units to
Be aware of medications that are in mcg vs. mg (e.g., thyroid, fentanyl patches, inhalers).
Ensure the proper formulation of the medication is documented especially long acting vs. short acting (CR, SR, XR, ER, LA).
For medications dispensed as partial tablets record the actual mg dose and not the dose as a proportion of
the tables (e.g., metoprolol 12.5mg orally twice a day; NOT metoprolol 25mg 0.5 tablet orally twice a day)
Avoid using abbreviations, identified as easily misinterpreted or involved in medication incidents leading to harm