Medication Reconciliation: A Learning Guide

How to Obtain the Best Possible Medication History (BPMH)

The purpose of this section is to explain some of the tips and techniques used to obtain the BPMH. It is beyond the scope of this module to teach this skill to all healthcare providers.

A Best Possible Medication History (BPMH) is a medication history obtained by a healthcare provider which includes a thorough history of all regular medication use (prescribed and non-prescribed), using a number of different sources of information. The BPMH is different and more comprehensive than a routine primary medication history (which is often a quick patient medication history).

The BPMH involves a:

1. Patient medication interview where possible.
2. Verification of medication information with more than one source as appropriate including:
   • family or caregiver
   • community pharmacists and physicians
   • inspection of medication vials
   • patient medication lists
   • medication profile from other facilities
   • prescription drug claim histories of Ontario Drug Benefit (ODB) recipients (Drug Profile Viewer)
   • previous patient health records

The BPMH includes drug name, dose, frequency and route of medications a patient is currently taking, even though it may be different from what was actually prescribed. Using tools such as a guide to gather the BPMH may be helpful for accuracy and efficiency. (A BPMH Interview Guide is available as Appendix 2 to this module).

If a patient is unable to participate in a medication interview, other sources may be utilized to obtain medication histories or clarify conflicting information. Other sources should never be a substitute for a thorough patient and/or family medication interview.

For patients who present prescription bottles and/or a medication list, each individual medication and corresponding dosing instruction should be verified, if possible. Frequently, patients take medications differently than what is reflected on the prescription label. Also, patients may not have updated their personal list with newly prescribed medications.

Team Exercise

This excercise is also available as a PDF.

Discuss the use of the BPMH interview guide with other members of your team. Is it feasible to use this tool in your unit? What barriers are there to using the tool? Is it feasible in some cases to complete the BPMH before admission medication orders are written?

Where should the BPMH be documented?

The BPMH can be documented in a paper-based or electronic format. It should be placed in a highly visible place in the patient’s medical record for all healthcare providers to access. There are many examples of BPMH forms that have been developed by different healthcare organizations.

An example of a BPMH form is available as Appendix 3 to this module.

The BPMH form used at this hospital is available as Appendix 4 to this module.

When should the BPMH be completed?

The BPMH should be completed as soon as possible after the decision to admit the patient has been made, and identify and reconcile discrepancies within the first 24 hours of admission.

Admission medication reconciliation processes generally fit into two models: the proactive process, the retroactive process or a combination of the two. Each team will need to determine what best practice works best for them based on staffing and patient characteristics.

In the proactive process, the BPMH is conducted prior to (e.g., in pre-admission clinic or emergency department) or upon the patient’s arrival on the unit and is used by the prescriber to write the AMOs. Some teams have created paper based or electronic formats to document the BPMH that leads to AMOs by providing room for the prescriber to indicate whether the medications should be continued, discontinued or modified. (See Appendix 5 – Sample BPMH to Admission Order Form, Capital Health, Nova Scotia.)

Proactive Medication Reconciliation Model

In the retroactive process, the BPMH is conducted after the AMOs are written. The retroactive process is used when staff are unavailable to perform a BPMH upon admission, the patient is too ill or complex, or there is incomplete information available to complete a BPMH prior to the AMOs. The BPMH should be conducted within 24 hours of admission.

Retroactive Medication Reconciliation Model

Who should complete the BPMH?

The BPMH may be completed by any healthcare provider (e.g. doctor, nurse, pharmacist) who:

1. Has received formal training on how to complete a BPMH.
2. Follows a systematic process such as a BPMH interview guide where possible.
3. Is conscientious, responsible and accountable in conducting the BPMH process.

Summary

• When taking a medication history, use a BPMH interview guide
• Whenever possible, conduct the BPMH prior to or at the time of admission
• When completed, the BPMH is placed in the patient’s medical record