Appropriate education and provision of information to patients about their medications is essential to encourage safe and effective use. This may include the supply of a medicines list (or profile), education about the medications and any changes, and consumer medicines information (CMI).

To provide timely medication education to patients.

To provide medicines lists to the patients who may benefit most on discharge.

Consumer medication information (CMI): is a leaflet that contains information on the safe and effective use of a prescription or pharmacist-only medicine. The information has been written by the pharmaceutical company responsible for the medicine.

Counseling: A verbal explanation of the purpose of a prescribed medication and proper administration including length of therapy, special directions for use, correct storage, ongoing supply instructions, information on adverse effects (including guidance on what to do if these occur), potential interactions and contraindications to the use of the drug.

HARP medication home visit: a comprehensive medication review conducted by a Hospital Admission Reduction Program (HARP) pharmacist in the patient’s home, ideally within 7 days of discharge.

HMR: Home Medicines Review. This is undertaken through a comprehensive medication review conducted by an accredited pharmacist in the patient’s home, and is generally organised through a community pharmacy.

Medication: refers collectively to medications, medicines, drugs or therapeutic agents administered by any route.

Medicines list: a list of medicines and their instructions for use provided to the patient at discharge from a health organisation.

Patient: patient, client or resident.

Variable dosage chart: a written document used to outline medication doses that change over the course of treatment (e.g. a prednisolone reducing dose over two weeks) in order to assist patient adherence.

Medication counseling

Patients and carers should be provided with sufficient information about treatment options for them to make informed choices about their medications and to achieve adherence. The information should be provided in a form that can be used and understood.

Principles include;

• All patients will be offered medication counseling during their presentation or admission.
• Medication counseling should occur throughout the patient’s admission where clinically appropriate, and is critical on discharge to assist the patient with adherence and prevent readmission.
• Medication counseling should be personalised to the patient.
• A variety of approaches are utilised including verbal counseling and written information e.g. medicines list, consumer medication information (CMI) leaflet.
• The patient should be offered counseling when commencing any new medication which is likely to be long term (i.e. continue for six weeks after discharge). For short term medications (e.g. analgesics, anti-nausea medications), abridged counseling may be provided at the point of administration (e.g. this is your antibiotic that is used to treat infection).
• Where necessary, priority should be given to patients requiring counseling for high risk medications (See High Risk Medications CPP0549). Specialised information may be sourced for this purpose.
• Documentation of medication counseling is recorded in the patient’s medical record or other applicable record for the consultation (e.g. the medical records copy of the discharge prescription or the electronic Best Possible Medication History).
• For patients who do not speak English as a first language, where available or applicable, the use of the interpreting service (NCP0016 Communication Access – Interpreting Service) should be considered.

Medication counseling would usually be conducted by a pharmacist. If a pharmacist is unavailable (i.e. no pharmacy coverage in the area, pharmacy department is closed) medication counseling should be conducted by other clinical staff (i.e. nurses, medical officer) or a pharmacy referral completed (see Pharmacist - Referral Process For Inpatients - CPG0046).

Warfarin counseling

• All patients commenced on warfarin will receive in depth counseling.
• When the counseling has been completed it will be documented in the designated section of the medication chart (MR/700.2) or in the progress notes if the patient has a long stay NSMC (MR/715.2 or MR/715.1) or the Warfarin and Anticoagulation Dosing Summary (MR/092.2).
• All patients commenced on warfarin will be offered an “Important Information for Patients on Warfarin” booklet.
• All patients will be provided with written information on their dosing schedule and next INR (where applicable). This may be included in their medicines list, an “Important Information for Patients on Warfarin” booklet or other appropriate information source.
• Patients who took warfarin prior to admission must have their understanding of the medication reviewed, and this documented on the medication chart.

Medicines list on discharge

A medicines list outlines all the medications the patient should be taking once discharged from hospital.

Core elements include;

• Patient name & UR number
• Date of generation.
• Active ingredient and common brand names
• Dose, route and frequency of administration
• Reason for use (indication)
• Duration of therapy (where applicable, e.g. short courses of antibiotics or analgesics)
• Any changes to medications taken prior to admission (e.g. new medications, ceased medications).
• Contact details for the pharmacy.

A medicines list can only be issued once the discharge prescription is completed and reconciled by a pharmacist. As per Medications - Patient Discharge & Transfer Process - CPP0434 the discharge script must be written, as early as possible upon anticipated discharge (when it is deemed appropriate and safe to do so) to facilitate the timely generation of the medicines list. Timely generation of the medicines list are likely to allow the patient to review their medicines list prior to discharge from the hospital.

The medicines list is prepared by the Pharmacy Department using the iPharmacy dispensing program. Medicine lists can only be generated during pharmacy opening hours. Requests for medicines list for patients discharged outside of these hours may be accommodated (e.g. referral via BOSSnet Allied Health E-referral).

All medicines lists are checked by a pharmacist before they are issued. The checking pharmacist signs and prints their name at the bottom of the list.

A medicines list should be supplied on discharge for patients who are deemed as high risk using the following criteria:

• Taking 5 or more regular medications OR
• Taking 12 or more doses of medication per day OR
• The patient express or display difficulty in managing medications OR
• The patient have significant changes made to his/her medications during admission OR
• The patient is aged over 65 years old and taking 3 or more regular medications OR
• The patient is deemed at significant risk of mismanaging his/her medications (in conjunction with other strategies) OR
• The pharmacist, patient and/or carer believe that a need exists.

Paediatric patients with complex administration instructions may also be considered for a medicines list for their carer.

Requests for a medicines list where the patient is not considered high risk will be accommodated where possible.

A medicines list may not be provided to a high risk patient when;

• The patient declines a medicines list or, already has an up-to-date list.
• There are no changes to the patient’s regular medications.
• Despite meeting the criteria, the patient is not considered at risk of medication misadventure.
• The patient is undergoing a day procedure or presents to the emergency department.
• The patient has a Dose Administration Aid prepared by a pharmacy.
• The patient is being discharged to another healthcare facility (e.g. hospital, residential care facility)

The medicines list is produced in triplicate with copies provided to;

• The patient or their carer.
• The patient’s general practitioner.

A copy will be scanned into the patient’s digital medical record under the applicable admission.
A copy may be supplied to other health practitioners as required (e.g. community pharmacy). Verbal consent must be received from the patient. See Clinical Handover Protocol - CPP0571.

A variable dosage chart may also be prepared for patients who are discharged on complicated regimens, e.g. prednisolone reducing scale. A variable dose chart may be provided in addition to, or in isolation to, a medicines list.

A medicines list is a tool to assist with improving the patient’s medication management, and should be provided in conjunction with other strategies (including comprehensive counseling, referral for a HMR or HARP medication home visit).