medicines partnership
medicine review
medicines partnership home medicines review home

go: [ Home  /  Medication Review  /  Room for Review  /  The Guide  /  Get Started  /  Records ]

Recording Reviews

Local guidance for medication review needs to cover how reviews will be recorded. There is currently no universally agreed way of documenting medication review.
 
Many organisations have defined their own approaches to meet local needs, but this means every local organisation having to re-invent the wheel, and fails to provide common data to measure progress nationally or to provide information which people can use to compare their own performance with that of others.
 
Some practitioners use Read codes to document reviews, but many GPs and practices have been discouraged by the complexity of the Read coding system and by regular reports of its imminent demise. As long as the system is in place, using Read codes for recording medication review has the potential to enable:
  • Consistent and easier data recording and retrieval
  • Data to be used for monitoring, analysis and audit
  • Feedback to practitioners to improve clinical activity
  • Tracking achievement of NSF targets and local priorities
  • A common clinical language to be shared between primary and secondary care, minimising risk and reducing potential duplication.
 
Within the existing system there are many alternative Read codes available for recording medication review. We recognise that there are limitations in the area of medication review including a lack of clear definitions. In the interests of clarity, consistency and comparability, we are consulting with the NHS Information Authority (NHSIA) to investigate the feasibility of agreeing a set of common recommended codes for recording the different types and outcomes of review referred to in section 3 of this guide. This still leaves scope for individual organisations to define their own local sub-codes in order to capture more detailed information if they wish.
 
Practitioners and organisations will need to decide locally how best to record reviews and consider the usual medico-legal and confidentiality aspects concerning clinical recording. There is useful guidance about confidentiality on the NHSIA's web site, www.nhsia.nhs.uk/caldicott.
 
Practices can also introduce local Read codes if required. However, in the medium to longer-term, and until the availability of a range of more useful Read codes we suggest that:
  • the 8B code and its sub-codes offer the greatest flexibility for recording and searching purposes.
 
Taking account of the likelihood of national improvements or changes to existing clinical terminology coding, we suggest local discussions about recording medication reviews and consideration of the following codes to record the level of review.
 
 LEVEL OF MEDICATION REVIEW
  SUGGESTED READ CODES 

Level 1:
Prescription or technical review of a list of the patient's medication under the direction of a doctor, nurse or pharmacist, but in the absence of the patient

 
  8B3h
  (medication review
  without the patient)

Level 2:
Treatment review under the direction of a doctor, nurse or pharmacist, in the absence of the patient but with reference to the patient's clinical record

 
  8B314 (medication review)
  or for systems with 4 byte
  coding only
  8B3S (medication review)

Level 3:
Clinical medication review specifically undertaken by a doctor, nurse or pharmacist in the presence of the patient with access to the patient's clinical record and laboratory test results as required

 
  8B3V
  (medication review done)

  
There is no requirement for practices who are not using Read codes, or who currently use different Read codes to switch to those above. This will be for local decision. But it is important to introduce a consistent approach in each practice, whereby types of reviews are recorded the same way. A fuller description of the Read coding system and guidance about how to use it is provided by the NHS Information Authority at www.nhsia.nhs.uk