Admissions: Recording Pre-Hospital Medications

Pre-hospital medications are the medicines a patient is taking prior to hospital admission, including prescriptions, over-the-counter medications (OTC), and complementary therapies. Recording these medications is the first step in obtaining a Best Possible Medication History (BPMH), providing the foundation for accurate medication reconciliation and safe prescribing.

If you are instead looking for instructions on prescribing a medication, please see Admissions: Prescribing Medications. 

Contents

1. Documenting Pre-Hospital Medications
2. Prescribing a Pre-Hospital Medication

Documenting Pre-Hospital Medications

1. Navigate to Admissions in the side-navigation
2. Open the Medications section
3. Select Pre-Hospital
4. Click on New Medication
5. Select a Medication Type by clicking either the Regular or PRN button

6. Enter the generic medication name into the Medicine field, and select the relevant option from the drop-down menu.
   
    

   ℹ️ Note: As patients may not know all details of their medications, only the Medicine field is mandatory when recording a Pre-Hospital Medication. All other fields are optional, and can be entered if known. Otherwise, if you are only aware of the Medicine name, you can click Save to finish adding the Pre-Hospital Medication to the patient's record.

    

7. If you would like to continue adding more information about the medication, please continue below. Otherwise, click Save to finish adding the Pre-Hospital Medication.

📌 Important: Any allergies recorded for the patient are displayed in the left panel. If a potential interaction is identified for the selected medicine you have chosen, it will appear in the Interactions box below the Allergies list. The Interactions box only loads after a medicine has been selected. For more information, see Medications - MediSpan Clinical Decision Support Interactions Service.

8. If you would like to specify a Brand for the medicine, enter this into the Brand Name field. 
   
   
    

9. Enter the Strength by free-typing into the field provided. Units are specified at a later stage in the workflow.
   
   
    
10. Begin typing the Form into the Form field, and select the relevant option. Alternatively, you can click into the Form field, scroll through the available options, and select as required. 
    
    
     
11. Begin typing the Route into the Route field, and select the relevant option. As above, if you prefer, you can  click into the Route field, scroll through the available options, and select as needed.
    
    
     
12. Enter the Dose by free-typing into the field provided.
    
    
     
13. Begin typing the Units into the Units field, and select the relevant option. You may also click into the field, scroll through the available options, and make an appropriate selection if preferred.
    
    
     
14. If you selected the Regular Medication button at the beginning of the workflow, move onto step 15. If you selected PRN at the beginning of the workflow, then you will have access to an extra field - the Max Dose/24Hours field. Enter a maximum dose if applicable.
    
     
15. Under the Frequency Type, select from the Pre-Defined and Manual buttons provided.
    • If you have selected Pre-Defined, click into the Frequency Name field, select a relevant option (ie Once a day), and enter any Administer Times required by typing or clicking on the clock icon to select a time.
      
      
       
    • If you weren't able to find an appropriate Pre-Defined Frequency, you may prefer to use Manual. Enter a Frequency Name, select a Frequency, choose a Repeat Every interval, and select an Intake.
      If you have selected Hourly Intervals, select the Hourly Interval from the field provided, and select a Start Time. 
      If you have opted for Number of Administration Times, select from the options provided, and input the Times for each Administration Time by typing or clicking into the clock icon beside each Administration Time. 
      
      
       
16. Click into the Indication field, begin typing, and select from the relevant options.
    
     

17. The Start Date for the medicine will default to the current date. If you would like to change this date, click the calendar icon and select the relevant date from the calendar provided. 
    
    
     
18. If required, enter an End Date, or click onto the calendar icon to select a date from the calendar provided. If you choose not to enter an End Date, then the medicine will automatically be ceased once the patient is discharged.
    
    
     
19. Enter a Review Date for the medication, or click onto the calendar icon to select a date from the calendar provided. 
    
     
20. If required, add Comments into the field provided.
    
    
     
21. The Pharmacy fields behind the toggle at the bottom of the window can be ignored for now. These are used by the pharmacist after the medication has been prescribed.
22. Click Save. 
    
    
     
23. The medication will then be visible at the top of the Pre-Hospital Medications grid with a status of Documented. Now that the medication has been added, if you were to prescribe another medication with an expected Interaction with this Pre-Hospital Medication, the Interaction will be displayed within the prescribing window at the time of prescribing. 
     

Prescribing a Pre-Hospital Medication

A pre-hospital medication can be documented and then quickly prescribed directly onto the medication chart from within the Pre-Hospital Medications window.

1. Open the Pre-Hospital tab of the Medications section within the patient's admission record
2. Select the ellipsis (•••) next to the documented medication, and select Prescribe
   
    
3. Complete all mandatory fields
4. Select Save to prescribe the medication to the medication chart

Related Reading

• Admissions: Prescribing Medications
• Admissions: Understanding Medication Charting
• Admissions: Editing & Ceasing Medications
• Admissions: Intravenous Infusion Charting (IV)