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PHARM29.2016 Retrieve and reconcile information about an individual's medicines


This standard is about the process undertaken to establish, reconcile and document an accurate list of each prescribed and non-prescribed medicine taken by an individual. This will involve retrieving information and confirming that the information is accurate. The standard can be applied in a variety of settings. Your practice will be consistent with your occupational role and carried out under the regulatory, professional and ethical frameworks established in the context of current legislation. You will need to take a reflective approach to your work. You will work at all times within Standard Operating Procedures that relate to the way in which a pharmacy service is provided in your work place. A caring and compassionate approach should be adopted in line with current healthcare guidance. Users of this standard will need to ensure that practice reflects up to date information and policies. Version No 2

Knowledge and Understanding

You will need to know and understand:
  1. the Standard Operating Procedures and the importance of adhering to them at all times
  2. the importance of working within the limits of your competence and authority, when to seek agreement or permission from others and when to refer on to an appropriate person
  3. current health and safety legislation and how it applies to the working environment
  4. legal, organisational and policy requirements relevant to your role, the role of others in your organisation and the activities being carried out
  5. the relevant national and local guidelines, policies and procedures that are available and how and when they should be accessed
  6. the importance of adhering to information governance policies and maintaining confidentiality when sharing information about individuals with others
  7. the duty to report any acts or omissions that could be detrimental to individuals, yourself, colleagues or your employer
  8. how to confirm and record the individual's allergy status
  9. the use of medicines including:
    1. dosing
    2. adverse effects
    3. common drug-drug interactions
    4. common drug-food interactions
    5. common drug-disease interactions
    6. cautions and contra-indications
  10. the prescribing conventions, abbreviations and medical terminology
  11. factors that may affect how medicines are taken
  12. the psychological, occupational and social aspects and implications for individuals living with conditions
  13. legislation and organisational processes relating to obtaining valid consent
  14. the actions to take if valid consent is not obtained
  15. methods of enabling effective communication and supporting individuals to communicate their needs, views and preferences
  16. how to create a suitable environment for an open and confidential discussion
  17. the need to confirm your role and responsibilities and the individual's identification prior to retrieving a relevant medication history
  18. when and how to retrieve the individual's identity and information from a third party where an individual is unable to participate themselves and/or where there are communication difficulties
  19. what evidence you should seek to demonstrate a third party's ability and authority to provide information about an individual
  20. the types of information that needs to be retrieved and why each is necessary
  21. the steps you would take to try to clarify and confirm any information which is ambiguous or missing from an individual's or third party's narrative
  22. how to use patient medication records or other sources of information to retrieve and confirm a medication history
  23. local and/or national error reporting procedures and communication channels
  24. the importance of recording, storing and retrieving information in accordance with organisational procedures and reporting any inconsistencies

Performance Criteria

You must be able to do the following:
  1. work within the relevant Standard Operating Procedures including the relevant health and safety procedures and within your own limits of competence
  2. ensure that the environment and timing is suitable for open and confidential discussion with the individual or third party about their medicines
  3. communicate with the individual and key people at a pace, in a manner and at a level appropriate to the individual's understanding, preferences and needs
  4. explain your role and responsibilities, introduce yourself and check the individual's identity according to local guidelines before retrieving an individual's medication history relevant to your work area
  5. obtain valid consent from the individual or third party in accordance with Standard Operating Procedures
  6. check the individual's or third party understanding of the purpose of retrieving an individual's relevant history
  7. check and record the individual's allergy status
  8. use appropriate questions to explore, clarify and confirm any unusual or ambiguous information and record the information clearly and accurately in a systematic manner
  9. identify and document the medicines and other substances, and ascertain from appropriate sources when and how they are taken by the individual
  10. use appropriate sources to identify details that are relevant to the individual's medication history including:
    1. medicines that have been started recently
    2. medicines that have stopped
    3. medicines that have changed
    4. medicines that are used regularly
    5. medicines that are used occasionally
    6. medicines that are swapped or shared between individuals or their family and friends
    7. medicines that are bought from other sources
    8. if the individual drinks alcohol, smokes or uses other substances
    9. if the individual has experienced any problems or difficulties with their medication
  11. report any problems, inconsistencies or adverse reactions that the individual may have experienced from their medication in line with Standard Operating Procedures
  12. reconcile and compare the medication history to the individual's current list of medicines
  13. identify and document any discrepancies, changes, deletions or additions
  14. complete all relevant documentation and store appropriately in accordance with legal and organisational requirements

Additional Information

This National Occupational Standard was developed by Skills for Health. This standard was merged with PHARM30. This standard links with the following dimension within the NHS Knowledge and Skills Framework (October 2004): Dimension: HWB6 Assessment and treatment planning
PHARM29.2016 Retrieve and reconcile information about an individual's medicines
Final version approved February 2016 © copyright Skills For Health,
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