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Good Prescribing Practice for Inpatients - Medicines Reconciliation, HEPMA and IDLs

This guideline provides brief guidance on good prescribing practice for inpatients. For more details see:

For guidance on the supply of medicines following specialist service review or clinic appointments, see medicine policy (section 5.10): Supply of Medicines Following Specialist Service Review or Clinic Appointments.

On admission - as soon as possible (within 24 hours)

  • Obtain a ‘Medication History’ and document in Clinical Portal:
    • Use a minimum of two information sources and record this as a 'Medication History' review in the Medicines Reconciliation / Immediate Discharge Letter (MR / IDL) system in Clinical Portal. The default information sources should be the Emergency Care Summary (ECS) and the patient where possible. Other sources of information include:
      • GP practice / District Nurses
      • Nursing home records
      • Community pharmacy
      • Patient’s own medicines
      • The Medication Summary or recent IDLs on Clinical Portal, or the Mental Health Summary
    • Always check the 'last updated' date on any source of information you use to ensure it is current and relevant.
    • Resolve any discrepancies between the information sources above.
    • Record allergies / sensitivities.
  • Complete an 'Admission Review' and document in Clinical Portal:
    • Consider the clinical appropriateness of each medicine, within the context of the patient’s current clinical condition and reason for admission, before deciding whether each medicine should be continued, amended, withheld or stopped. Document your decisions as an 'Admission Review' in the MR / IDL system in Clinical Portal.
      • See Assessing Medicines on Admission in Acute Patients for general principles to consider for each medicine the patient is taking on admission. Also includes important prescribing points for certain high-risk medications and conditions, such as insulin, clozapine, HIV medications and nephrotoxic drugs.
    • This process will facilitate the production of the IDL at discharge.

During admission

HEPMA (Hospital Electronic Prescribing and Medicines Administration) is used for the majority of inpatient prescribing. Paper prescription charts are used for specific medicines and in specific clinical settings.

 

General principles for prescribing

  • Where possible, ensure that the same prescriber completes both the Medicines Reconciliation and the initial prescribing task.
  • Ensure each new medicine is appropriate and safe for the patient by checking for allergies / sensitivities, history of adverse reactions, any factors which could affect the patient's ability to handle the medicine (e.g. renal or hepatic impairment, interactions, weight), presence of or risk factors for QT prolongation, GGC formulary status of the medicine, ability to take oral medicines, compliance issues.
  • Consent - Patient should be fully informed of any medication changes, and educated on adverse effects, necessary monitoring and reviews.
  • Confirm the patient’s name and CHI before prescribing.
  • Use generic medicine names wherever possible. If there are bioequivalence issues for different formulations, e.g. lithium, phenytoin or modified release preparations of verapamil, then prescribing should be by brand as a different brand can result in ineffective therapy or toxicity.
  • State the duration for courses of treatment, e.g. antibiotics or steroids.
  • Check if any doses have already been administered.
  • Clearly document any medication changes and the reason in the appropriate location of the patient's medical records (e.g. supplementary medicines prescription chart, medical notes).
  • Monitor patient for potential and actual adverse reactions.
  • Monitor clinical efficacy by adhering to any medicine-specific monitoring requirements, e.g. monitoring vancomycin plasma levels.
  • Continually review the need for each medicine, e.g. if patient is on IV antibiotics, then review daily and switch to oral therapy when clinically appropriate (see IV-Oral Antibiotic Switch Therapy (IVOST) Policy).

 

Electronic prescribing (HEPMA) - additional guidance

  • Only open ONE patient profile at a time.
  • Always use a patient’s CHI number to search for the correct patient (see relevant HEPMA alert).
  • Complete the VTE risk assessment. If VTE prophylaxis is required, it must then be prescribed.
  • Update the allergy section. HEPMA carries forward the allergy status from the previous admission and doesn’t prompt to complete this section (unless it is the first admission). Note: Combination drugs such as co-amoxiclav must be recorded as ‘amoxicillin’ and ‘clavulanic acid’.
  • Select the correct medication from the drop-down list. Type, as a minimum, the first 5 letters of the medicine to avoid mis-selection. Typing only the first 3 letters risks selecting the incorrect medicine, e.g. oxybutynin instead of oxycodone or carbamazepine instead of carbocisteine. If you cannot find the medication, try adding a % sign before the medicine name.
  • Carefully read any interaction or therapeutic duplication alerts that are presented when adding a new medicine. Contact pharmacy if advice on the appropriate action is required.
  • Prescribe the correct dose. HEPMA doesn’t alert if an overdose has been prescribed, e.g. if ramipril 25mg has been prescribed instead of 2.5mg.
  • Use an up-to-date weight (e.g. for enoxaparin or paracetamol). Weights from previous admissions are automatically pulled through to the current admission and may not be accurate.
  • Review all prescribing paperwork (including A&E and theatre charts) and adjust the date and time of first HEPMA dose accordingly.
  • HEPMA does not count PRN doses administered in a 24-hour period, so will allow doses to be prescribed and given at any time, regardless of when it was last given or if the maximum daily dose has been reached.
  • Carefully review the prescription before clicking ‘confirm’ and committing it to the electronic Kardex.
  • Inform nursing staff of any urgent ‘stat’ doses.
  • Ensure an awareness of relevant HEPMA ‘protocols’ for each clinical setting. Protocols are sets of medicines grouped together for prescribing in a single action, for example anticipatory palliative care medicines.
  • If oxygen is being administered, ensure that it is prescribed on HEPMA.
  • Note that, as unlicensed medicines and clinical trial medicines may not have an entry in the HEPMA ‘conflict database’, relevant interactions and allergies may not be flagged.

 

Paper prescription charts – additional guidance

  • Ensure medicines are written legibly and in full (do not use abbreviations for drug names).
  • 'Micrograms', 'nanograms' and 'units' must be written in full, e.g. 10U insulin could be misread as 100 units of insulin.
  • For liquids, prescribe doses in 'mg' rather than 'ml', as different strengths of liquids may be available.
  • Avoid decimal points if possible, e.g. '2mg' rather than '2.0mg'. If a decimal point is unavoidable, then carefully prescribe the dose, e.g. '0.3mg' rather than '.3mg'. Prescribing the dose in words as well as figures could also be considered, e.g. ‘2.5mg (two point five milligrams) levomepromazine’.
  • Sign, print name and date all prescriptions.
  • Supplementary paper prescription charts are used when prescribing is complex, and the full prescribing and monitoring regimen cannot easily be prescribed using HEPMA alone. The medicine must also be prescribed on HEPMA with ‘as per paper chart’ in the dose box. Example charts include:
    • Continuous IV infusion chart, e.g. for IV phosphate or IV magnesium
    • Insulin subcutaneous (SC) - If insulin brand or frequency changes, HEPMA must also be updated
    • Insulin variable rate (IV)
    • Acetylcysteine (IV)
    • Gentamicin (IV)
    • Vancomycin (IV)
    • Palliative Care Continuous SC infusion
    • Warfarin (oral)
  • Refer to the Medicines Prescription Charts StaffNet page [link only active via NHSGGC computer] for samples of the above charts. For information on how to prescribe insulin click here and for gentamicin/vancomycin click here.

On discharge

  • Prepare IDLs in adequate time to allow dispensing of the medicines (ideally 24 hours in advance of planned discharge).
  • Use the IDL to communicate clearly with the GP regarding new, stopped, changed, and withheld medications. Remember to consider durations if appropriate.
  • Obtain an up-to-date and accurate list of medications by reconciling the admission list of medicines*, the HEPMA list of medicines, and the inpatient medical notes. 
    • *Check carefully, as this list may represent medicines from a previous admission.
  • The following is advised for medicines with variable doses (e.g. warfarin and insulin):
    • Prescribe a frequency on the 'prescription' part of the IDL, but not a specific dose. For example, prescribe 'Take daily at 6pm, as directed'.
    • Document the dose and the frequency within the main body of the IDL letter.
    • Highlight, within the 'prescription' part, that the letter contains additional dosing information e.g. 'See IDL letter for current dose at discharge'.
    • These steps should reduce the risk of an out-of-date dose being used if the patient is re-admitted.
  • Ensure the patient or their relative / carer is aware of any medication changes.
  • For guidance on prescribing controlled drugs on discharge, see Controlled Drug Prescribing.
  • For guidance on dealing with compliance aids, see Compliance Aids.
  • Ensure the IDL pathway is ‘closed’ prior to discharge. Unclosed pathways pose significant risks to the patient, as medication changes will not be communicated to the GP. For further guidance on this, please see this Clinical Portal - Ward Tasks video.
  • If changes are required to medicines in the IDL after it has been sent for pharmacy review, then pharmacy must be informed immediately by phone so that changes can be made to the dispensed prescription.

Medication Incident Reporting

  • A medication incident is an error, adverse event or near miss involving a medicine which causes harm or potentially could cause harm to a patient. Many are preventable.
  • All staff (medical, nursing, pharmacy) must ensure that medication incidents are reported, even near misses. This is an important part of our learning system to make improvements to patient care.
  • Use DATIX [link only active via NHSGGC computer] to report all incidents. Incidents should be managed and investigated as per NHSGGC Incident Management and Recording Policy and Policy for Managing Significant Adverse Events [links only active via NHSGGC computer].

Compliance aids

These are used widely but may not always be suitable or appropriate for the patient.

It may be more appropriate to assess a patient for a new compliance aid after discharge to their home environment. If a new compliance aid needs to be set up prior to discharge, a member of the ward clinical team needs to discuss the suitability with the patient / patient's family / carer and identify if the patient's usual community pharmacy, or an alternative community pharmacy, would be able to continue this service long-term. This should be carried out at least 48 hours prior to discharge.

Use of a compliance aid (plus the name of the community pharmacy) should be documented at the following stages of the inpatient stay:

  • On admission via the ‘Medication History’ on Clinical Portal: add a ‘New medication’ and select ‘Compliance aid’.
  • During admission via HEPMA: add as a Patient Level ‘note to pharmacist’ and tick the box stating ‘retain note between spells’ if not already listed.
  • At discharge via the IDL on Clinical Portal: add a ‘New medication’ and select ‘Compliance aid’.

 

Guideline reviewed: April 2026

Page updated: July 2026