ISMP (US) Contact Us Feedback

Primary Care MedRec Guide

ISMP Canada logo HQO logo
Appendix 3: Medication Reconciliation Documentation Tips

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

BPMH Section Reconciliation Section
Date history is taken Discrepancies identified
Medication allergy and reaction information Actions taken to resolve discrepancies
Community pharmacy name and number Updated reconciled list (medication name, dose, route, frequency, start date, stop date, indication, prescriber name)
Medication management information (e.g., self-administration or caregiver administration; use of compliance packs) Name of person that completed the reconciled list
Sources of information used to complete BPMH  
Name (generic name preferred)  
Start date  
Prescriber name  
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 taken.
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
Pay particular attention to "High Alert" medications (e.g., anticoagulants, insulin, opioids, methotrexate)
Avoid using Latin abbreviations if the BPMH leads to a medication list for the patient.