How to Fill Out the Admission Best Possible Medication History (BPMH) Tool Medication Reconciliation On Admission Updated: August 21, 2014 Medication Reconciliation on Admission How to Fill Out an admission BPMH 1
Overview What is an admission Best Possible Medication History (BPMH)? The cornerstone of the MedRec process upon admission is to develop the BPMH. The admission BPMH is a single medication history/list that acts as the one source of truth which is shared and communicated across all disciplines for documenting the patient/resident s medication regimen prior to admission. The admission BPMH then becomes the reference point for: decisions to continue, discontinue, or modify the patient/resident s medication regimen upon admission; creating medication admission orders for the patient/resident once reviewed and signed by a prescriber; and determining the patient/resident s medication regimen upon external transfer/discharge To review the admission BPMH tool, please refer to Appendix A. To review an example of a completed admission BPMH tool is located in Appendix B. For guidance and tips on how to conduct a BPMH, please refer to the BPMH Interview Guide located in Appendix C. Medication Reconciliation on Admission How to Fill Out an admission BPMH 2
How To How to fill out a Best Possible Medication History (BPMH) This document will provide you with a step-by-step process of how to fill out an admission BPMH tool, broken down by each section/area of the tool. A copy of the admission BPMH tool in its entirety is found in Appendix A of this document. Information Sources Section: Ensure you affix the patient label to the upper right corner of each page Place check marks to indicate each of the sources used to complete the admission BPMH tool. Remember, ideally at least two sources should be used. Please see the following page for an explanation of the various information sources. Medication Reconciliation on Admission How to Fill Out an admission BPMH 3
Explanation of information sources: Patient Recall and/or Family Recall Medication Vials Bubble Pack/ Dosette MAR From other Facility This refers to interviewing the patient/resident and/or family using a systematic process. The aim is to identify the patient s actual use of medications. Wherever possible, try to interview the patient/ resident. Tip: An interview guide can be found in Appendix C of this document, and on CompassionNet. When patients/residents bring in their medication vials, use the Show and Tell Method. This means showing the patient/resident the vial/medication and asking open-ended questions about the medication. Ensure to check that the most recent pack has been provided and ask the patient if there have been any subsequent changes to it. Even if the patients/residents are unsure of their medications, keep them involved in the process. Sometimes patients/residents forget about a change until you ask them about a medication. Tip: Remember to ask about any additional medications not contained in the Bubble Pack. A Medication Administration Record (MAR) is applicable if it is current and accurate. This is available in the case of patients/residents arriving directly from another health care facility. Tip: Contact the facility or the facility s affiliated pharmacy if it is unclear whether it is a current MAR. Medication Discharge Plan Patient Home Medication List Alberta Netcare PIN Profile Pharmacy Ensure this is a recent plan. Double check with the patient to ensure the name of the facility and date of discharge. Tip: Additionally, the most recent discharge summary information may be already uploaded and available for viewing on Alberta Netcare, depending how recent the admission. It can be very helpful to have a home list. Confirm with the patient/resident that this list is up to date and reflects how the medications are actually being taken. Always print off a Netcare PIN Profile history for the past 6 months at minimum. Do not transcribe your BPMH list directly from this printout, because this may not reflect how the patient is actually taking their medications. Tip: It is best to proactively print out the PIN Profile before interviewing the patient/resident to use as a starting point for conversation. For information on the role of Alberta Netcare and PIN in MedRec,please refer to CompassionNet. This refers to the patient/resident s Community Pharmacy. Telephoning this pharmacy team can be a valuable resource for supplementing or clarifying information obtained from the patient/resident and/or Alberta Netcare PIN profile. Tip: Adding the telephone/fax number of the pharmacy contacted is helpful to ensure all care providers are clear which pharmacy was contacted. Medication Reconciliation Admission BPMH Interview Guide 4
How To Best Possible Medication History (BPMH) Section: Fill in the date and time your BPMH tool was completed. If there are no prescribed medications, check the No Prescribed home medications box. If the patient is taking prescription medications and/or prescribed Over the Counter (OTC) medications, record them in the space provided (Medication Name, Dose, Route and Frequency). Use Generic names. Note: the dose, route and frequency are written how the patient/resident is actually taking the medication. Immediately below the last entry, sign and indicate your designation. Self Prescribed (OTC) Medications Section: In the Self Prescribed (OTC) Medications section, you will write the medications a patient/resident is taking that were not prescribed (i.e. vitamins, herbals not prescribed by a prescriber). Comments Section: Use the comments section to inform the prescriber of any discrepancies, concerns or relevant additional information not captured elsewhere. Additionally, the comments section is a place to document how a medication was originally prescribed, if the patient/resident is currently taking any of the medications differently, and why. Medication Reconciliation on Admission How to Fill Out an admission BPMH 5
Prescriber Reconciliation Section: How To Using the Prescriber Reconciliation section, the prescriber will indicate whether to continue, discontinue or change a medication using a check mark in the appropriate box. If the prescriber is discontinuing or changing a medication, a reason for the change must be noted. If the prescriber is changing a BPMH medication, a new order must be written on the regular order sheets for the unit. Late Entries Note: The BPMH is not an order until the prescriber completes the prescriber reconciliation section, prints his/her name, the date, time and signs the document. Clerical staff may utilize the Copy to Pharmacy line to document the date and time the BPMH was scanned/sent to the inpatient pharmacy. Please ensure a copy of the completed tool is kept in the patient s chart. On the bottom right of the page, indicate the current page number as well as the total number of pages the BPMH will contain. If new information is learned about the patient/resident s preadmission medications after the initial BPMH is completed and signed, it is still important to capture this new information. Write a late entry on the BPMH tool itself. If there is room on the original BPMH, write Late Entry along with the name, dose, frequency and route of the medication, date, time and your signature. If there is no room, start a new Medication Reconciliation tool and renumber all associated pages. Additionally, write this information in the progress notes and notify the prescriber to address the discrepancy. Medication Reconciliation on Admission How to Fill Out an admission BPMH 6
Appendix A Best Possible Medication History (BPMH) Tool Medication Reconciliation Admission BPMH Interview Guide 7
Appendix B Completed Best Possible Medication History (BPMH) Example Medication Reconciliation Admission BPMH Interview Guide 8
Appendix C Interview Guide for Obtaining a Best Possible Medication History Introduction When you first meet a patient/resident, it is important to introduce yourself and state your profession; then ask if it would it be possible to discuss their preadmission medications with them (or a family member) and explain the rationale for this discussion. Example: Good morning. My name is Joan. I am a pharmacist working with the Family Medicine team and I am looking to gain a clear understanding of the medications you are currently taking at home. Would it be alright for me to ask you some questions about your medications, so I can create an accurate list for your chart? This will help the health care team make decisions about your care, and ensure none of your home medications are overlooked. Information Gathering Information gathering is a critical step to accurately obtaining a comprehensive list of the current and actual medications the patient/resident is taking. Be proactive and gather as much information as possible prior to seeing the patient/resident (i.e., Alberta Netcare Pharmaceutical Information Network (PIN) profile, copy of recent discharge summary, community pharmacy patient medication profile printout, etc.). Here are a few other tips to help you: When speaking with the patient/resident and/or family/caregiver: Avoid medical terminology, use simple terms. Ask open-ended questions Use medical conditions as a trigger to prompt consideration of appropriate common medications Use a show and tell method when they have their medications with them. How do you take your (medication name)? How often or when do you take (medication name)? Encourage questions from the patient Get details on PRN usage How often do you take this medication (i.e. in a day, week or month)? Collect information about dose, route and frequency for each drug. If the patient is taking a medication differently than prescribed, record what the patient is actually taking in the prescribed section, and note how it was prescribed in the comment section. Go through at least one other source (See Information Sources section of this document) and if you find there are any medications you did not already discuss, ask the patient about them. Medication Reconciliation Admission BPMH Interview Guide 9
Always Ask: Do you have your medication list or medication bottles/vials/dosette/bubble pack with you? Do you take any ASA (acetylsalicylic acid)? Do you take any over-the-counter medications (OTCs)? Do you take any vitamins/minerals/supplements/herbals? Do you use any: Eye drops Ear drops Nasal sprays Inhalers Medicated creams or ointments Medicated patches Injections Doctor Samples Recreational Drugs Have you used any antibiotics in the past 3 months? If so, what are they? (Put this information in the comments section on the BPMH) Are there any prescription medications you (or your physician) have recently stopped or changed and what is the reason for this change? Conclusion To conclude, thank the patient/resident and/or family/caregiver for their time and reassure them the importance of this process. Allow for questions and address any concerns and explain how you can be reached if issues arise after the interview (the manner in which they are instructed to contact you will differ based on your role and practice area). Example: Do you have any questions or concerns? If you think of anything else later, please notify your nurse who will contact me; I will be happy to update the information and/or answer any of your questions or concerns. Thank you so much for your time and for helping me to gather this important information for your care. Note: If new information is learned about the patient/resident s preadmission medications after the initial BPMH is completed and signed, it is still important to capture this new information. See Page 6 (Late Entries) for details. Adapted From Best Possible Medication History Interview Guide By: ISMP, Safer Healthcare Now and UHN Medication Reconciliation Task Force Medication Reconciliation Admission BPMH Interview Guide 10