Acute Hospital Trusts

Trusts are separate legal entities and will have their own organisational medicines policy for the safe and effective management of medicines in the hospital e.g. in relation to prescribing, storing, transporting, supplying, administering and disposing of medicines.  Refer to your relevant local policies, which can usually be accessed via the Trust’s intranet


Medication Documentation

There are usually three main prescribing documents in hospitals:

  1. Inpatient prescription and medication administration record (commonly known as a drug chart)
  2. Outpatient Prescription (note some Trusts use hospital FP10 prescriptions)
  3. Discharge Summary which includes the discharge medication prescription (also known as ‘TTA’ (‘to take away’) or ‘TTO’ (‘to take out’))

As part of the long-term plan for the NHS, Trusts are transitioning from paper to Electronic Prescription Medication Administration (EPMA), which is the implementation of an electronic prescribing and medicines administration system.  Some Trusts have already moved to EPMA and an induction is usually provided.


Hospital Inpatient Prescribing

The inpatient prescription and medication administration record or drug chart, is an example of a Patient Specific Direction (PSD) and does not have to follow prescription writing regulations (unlike outpatient prescriptions and discharge medication summaries, which do).  A PSD is the traditional written and signed instruction by a prescriber for medicines to be supplied and/or administered to a named patient after assessment of the patient on an individual basis. 

  • Each Trust will have guidance and standards on how to complete the drug chart
  • Drug charts can vary between Trusts – familiarise yourself with your Trust's drug chart(s) or ask your ward pharmacist to talk you through it
  • Inpatient drug charts always include patient information and allergy details, in addition they have different sections (the list below is not exhaustive and may vary between Trusts):
  • Once Only Medications (‘stat’)
  • Regular Medications
  • As Required Medications (‘prn’)
  • Infusion Charts
  • Some Trusts may have a specific area for medicines or groups of medicines on the drug chart e.g. antimicrobials, antidiabetic medicines, insulin, anticoagulants, oxygen
  • Other areas of a drug chart may include a medicines management section, where the patient’s medication history prior to admission is documented and there may also be a separate section for VTE (venous thromboembolism) risk assessment
  • There may also be additional drug charts or prescriptions e.g. diabetic prescription chart, parenteral nutrition prescription, chemotherapy prescription, patient controlled analgesia (PCA) prescription, epidural prescription, syringe driver prescription 
    • If any are in use for a patient, it should be documented on the main inpatient drug chart and all charts should be held securely together
  • Some specialist wards or clinical areas may have their own specific drug chart e.g. ITU and paediatric wards
  • Administration routes are generally indicated as below, however always check your local Trust policy.  Routes include:
  • IM - intramuscular
  • INH - inhalation
  • IV - intravenous
  • NEB – nebuliser
  • NG - nasogastric
  • PO - oral
  • PR - rectal
  • PV – vaginal
  • SC – subcutaneous (care should be taken as SC written unclearly can look like SL)
  • SL – sublingual (care should be taken as SL written unclearly can look like SC)
  • TOP - topical
  • Times of administration are usually pre-printed on the drug chart and can be amended by the prescriber if required e.g. when the time interval between amoxicillin doses needs to be spaced out evenly
  • If new to a Trust, always view some completed inpatient charts before attempting to administer medicines or if unsure ask your ward pharmacist or your supervisor for assistance


Inpatient Medication

  • Each Trust will have their own local formulary, which lists the medicines approved for prescribing within the Trust
  • Some Trusts have a formulary specific to their hospital, whilst others may have a joint formulary which covers not only their hospital Trust but also primary care
  • In some Trusts the content of the BNF is integrated into the local formulary through a web-based application
  • Non-formulary medication can be obtained, but with the Trust’s permission - ask the pharmacist for further details
  • Most Trusts encourage patients to bring in their own medication, which assists in determining patient medication history and also reduces the risk of omitting or delaying doses of crucial and/or critical medication
  • If a patient’s own medicines are deemed suitable, they are usually stored in the patient’s bedside medicine locker to be used for administration during their hospital inpatient stay
  • Inpatient medication is ordered by the pharmacy team, and usually dispensed and labelled with full directions
  • This ensures the patient can take the supply with them on discharge, provided it matches their discharge medication summary
  • The medication history carried out by medical staff at initial assessment has to be confirmed for accuracy and documented within 24 hours of admission by a suitably trained member of the pharmacy team
  • Any discrepancies identified in the medication history must be resolved and changes documented – this process is known as medicines reconciliation
  • Pharmacists provide a clinical pharmacy service to most wards 
  • Once the pharmacist has carried out the necessary clinical checks for each medicine, it is customary to endorse and sign the drug charts in green ink 
  • This also distinguishes pharmacy input from the prescribing process
  • It is normal for pharmacists to discuss prescriptions with the prescriber for clarification and provide medicines management support to doctors and nurses
  • A medicines information service is usually available as part of the pharmacy department 
    • This service can be accessed by all healthcare professionals for any medicines related queries


Discharge Medication

  • The discharge medication prescription must follow prescribing writing regulations
  • Depending on Trust Policy, patients will usually be provided with at least 7 to 14 days medications on discharge, but this can vary according to the Trust
  • Details of the discharge medication and the prescription are often part of the discharge summary
  • To prevent delays in discharge, once a discharge prescription is written, the Pharmacy team must be informed in a timely manner
  • On discharge, a copy of the summary is provided to the patient and also sent to their GP
  • The summary must state if a discharge medication is to be stopped, continued or the dose titrated along with any monitoring or review requirements
  • If any medication during the hospital admission was discontinued, changed or newly started, this must be stated on the discharge summary with the reason why


Outpatient Medication

  • Outpatient prescriptions vary between Trusts but must follow prescribing writing regulations
  • In some Trusts, outpatient prescriptions are dispensed by community pharmacies located on the Trust premises rather than the hospital pharmacy department
  • Usually urgent or hospital-only medications are prescribed on an outpatient prescription
  • In England, prescription charges apply unless exempt
  • Some Trusts allow use of a hospital FP10 (FP10HP) which can only be dispensed by a community pharmacy


Transfer of Care

  • Ensure communication is complete and clear when transferring care
  • It should be specified who is responsible for monitoring and reviewing the patient