Admission medication history template

Australian documentation guide

A pharmacy admission record that separates the medicine history and its sources from the pharmacist's assessment and documented recommendations. It provides a scaffold for recording information, not a prescribing plan.

The blank template

REASON FOR ADMISSION: [ ]
PAST MEDICAL HISTORY: [ ]
MEDICATION HISTORY: [ ]
ALLERGIES & ADVERSE REACTIONS: [ ]
SOCIAL & LIFESTYLE HISTORY: [ ]
PHARMACIST ASSESSMENT: [ ]
PLAN & RECOMMENDATIONS: [ ]

How to fill it in

Copy the blank template into your record system.
Fill in what was discussed or assessed. Keep uncertainty visible, and use [not stated] where required information is missing.
Check the details and any gaps before saving or sharing. The clinician must explicitly confirm any generated content.

Reason for admission

Record the stated reason for admission and the source of that information. Distinguish a provisional problem from a confirmed diagnosis. This context does not authorise assumptions about which medicines a person should take.

Past medical history

Record relevant established conditions and procedures, with source and timing when available. Identify uncertain entries or history not obtained. Do not infer a condition solely from a medicine on the list.

Medication history

Establish what the person actually reports using, including prescribed, non-prescription and complementary products when elicited. Attribute each source, such as the person, carer, containers or a documented list.

For each medicine, preserve the known name, strength, formulation, dose, route, frequency and relevant last use. Distinguish regular, as-required, ceased and uncertain use. A dispensing entry or prescription is not by itself proof of current administration.

Allergies and adverse drug reactions

Establish the substance and reaction, who reported it and whether details were verified. Preserve the recorded classification; do not resolve an allergy-versus-intolerance question without an expressed assessment. “No known reaction”, “not asked” and “unable to obtain history” convey different facts.

Record relevant information obtained about managing medicines, available support and reported practical difficulties. Describe specific facts, such as who prepares a dose aid, rather than labelling someone “non-compliant”. Do not infer adherence from appearance, age or living alone.

Pharmacist assessment

Record the pharmacist’s stated interpretation of the established history, including uncertainties and identified discrepancies. Distinguish an observation from a proposed explanation. A missing dose remains unknown; this template does not calculate or select one.

Plan and recommendations

Record recommendations actually made and their status: proposed, communicated, accepted, declined or awaiting review. Name the recipient and follow-up owner when established. A recommendation is not evidence that an order was changed or a medicine administered.

Common omissions

The source and date of a list, actual use of as-required medicines, formulation, last use and uncertain reaction details can disappear when histories are combined. Conflicting sources should remain identifiable.

Review before saving

Check that current use is distinguished from prescribing and dispensing history, and that unresolved information remains explicit. Preserve the boundary between a pharmacist’s recommendation and an authorised prescribing decision. Use local medication-history and documentation procedures.

Worked examples

A medicine history before a planned procedure

Fictional example. Made up for this guide; no patient record was used. It shows how to write a record, with gaps left visible. It is not a care plan or a record to copy into someone's chart.

REASON FOR ADMISSION: Admission for a planned skin procedure, as recorded by the admitting team.
PAST MEDICAL HISTORY: Person reports no chronic condition. Existing practice summary was checked; no additional condition was identified in the supplied summary.
MEDICATION HISTORY: Person reports no regular prescribed or non-prescribed medicines. Community pharmacy confirms no current regular dispensing on its record. This does not establish use of products obtained elsewhere.
ALLERGIES & ADVERSE REACTIONS: Person reports no known medicine allergy or adverse reaction. Hospital allergy record shows the same reported status.
SOCIAL & LIFESTYLE HISTORY: Person manages their own medicines. They report no tobacco use; alcohol history was not discussed in this focused interview.
PHARMACIST ASSESSMENT: Pharmacist records no regular medicine identified from the sources checked. Products obtained outside the nominated pharmacy remain limited to the person’s report.
PLAN & RECOMMENDATIONS: Pharmacist documents the sources and limitations in the admission record and hands the verified history to the admitting team. No medicine change is recommended in this example.

History obtained before a full medicine list is available