A common issue we identify during inspections or complaints activity is poor and ambiguous medication recording.

This document gives common sense guidance on medication recording and care plans. It provides the opportunity for care services to review their medication policies and procedures to ensure they cover all legal requirements and best practice relating to medication recording, reviews, monitoring and care planning. 

The guidance is a useful starting point to open up dialogue between care services, their supplying pharmacy, GPs, relatives and carers, and training organisations to improve the quality of medicines management within the service.