Clinical template
Medication List Template
A medication list is a best possible medication history (BPMH), not a photocopy of last year's EMR field. Include what the patient swallows, inhales, injects, applies, and sleeps with (CPAP, pumps). Capture dose, route, frequency, indication, and whether they actually take it.
Blank BPMH
Use at admission, new-patient visits, and before discharge med rec. Date the list and name the sources. A list with no source is a rumour.
Medication list (BPMH)
Patient: Date / time: Compiled by: Sources used: patient / SDM / vials / blister pack / community pharmacy / provincial drug system / prior BPMH / discharge letter Pharmacy (name, phone): Compliance packaging: Y/N Allergies / intolerances (linked, not instead of the allergy field): Prescriptions Drug — dose — route — frequency — indication — last taken — adherent Y/N/partial — prescriber if known Inhalers / nasal sprays / nebules: Topicals / patches / eye-ear drops: Injections (insulin, GLP-1, anticoagulants, biologics) — device and time of day: OTC / vitamins / herbals / recreational: Devices (CPAP pressure if known, insulin pump, glucometer, spacer, nebulizer): Recently stopped (drug, when, why): Cannot confirm (drug, why uncertain): Discrepancies vs EMR / vs provincial profile:
Fictional patients
The example is made-up. BPMH is a clinical procedure used in Canadian hospitals and increasingly in clinic. It does not replace pharmacy verification for high-alert drugs when you have a pharmacist.
What 'best possible' means
One source is not enough when the decision is hold metformin, reverse warfarin, or restart a beta blocker. Interview the patient with bottles on the table when you can. Call the pharmacy. Open the provincial viewer if you have access (PharmaNet in B.C., Alberta Netcare PIN, Québec DSQ, and similar systems elsewhere). Samples, cannabis, and internet peptides will not be on the provincial profile. OTC NSAIDs and sleeping tablets often will not either.
| Include | Often missed | Do not treat as complete |
|---|---|---|
| Regular and PRN prescriptions with dose and frequency | Inhalers, eye drops, patches, depot injections, methotrexate weekly | EMR list last updated 18 months ago |
| OTC analgesics, antacids, iron, vitamin D | Herbals, cannabis oils, 'men's health' capsules | Patient memory of 'a water pill' with no name |
| Insulin type, concentration, times | Sliding scales, correction factors, pump basal | A discharge MAR from a different admission without a home comparison |
| Devices that deliver drug or change risk (CPAP, spacer) | Samples from a specialist, trial bottles | Pharmacy profile alone in a patient who uses two pharmacies |
How to write each line
Name, strength, route, frequency, indication. 'Metformin 1000 mg PO BID for T2DM, last dose this morning, adherent' can be acted on. 'Metformin' cannot. For weekly drugs, write the day. For patches, write where and when changed. For insulin, write the product name, not only 'insulin.' If they take half a tablet, write that. If they skipped ACE inhibitor for two weeks because of a cough, that skip is part of the list.
- High-alert: anticoagulants, insulin, opioids, immunosuppressants, chemo — indication and last dose time.
- Duplicates: two pharmacies filling the same statin, or a brand plus a generic.
- Look-alike doses (once weekly vs once daily methotrexate) — write the schedule in words.
- PRN that has become daily (hydromorphone, zopiclone, ibuprofen) — record actual use.
Example — clinic BPMH
Pre-admission clinic, hip replacement
76-year-old woman, Hamilton. Sources: patient, dosette, pharmacy fax, EMR. Fictional.
Patricia W., 2026-08-26 11:00. Compiled by RN Cole / reviewed Dr. A. Singh. Sources: patient + 7-day dosette + community pharmacy fax (Shoppers) + EMR list. No provincial viewer access this visit. Pharmacy: Shoppers, dosette weekly. Allergies: codeine — nausea (not rash). Prescriptions Ramipril 5 mg PO daily — HTN — this morning — adherent — GP Bisoprolol 2.5 mg PO daily — HTN / rate — this morning — adherent — GP Atorvastatin 20 mg PO qhs — CV risk — last night — adherent Metformin 500 mg PO BID — T2DM — morning dose taken, evening due — adherent Empagliflozin 10 mg PO daily — T2DM — this morning — adherent **hold 3 days pre-op per anesthesia** Pantoprazole 40 mg PO daily — GERD — this morning Acetaminophen 500 mg 2 tabs PO TID — OA — actual use ~2 g/day Hydromorphone 1 mg PO q4h PRN — OA — takes 1–2 tabs most evenings, not in dosette Latisse/other: none Inhalers: none Insulin: none OTC: vitamin D 1000 IU daily; ibuprofen 200 mg 'a few times a week' for hip — last 2 days ago Herbals: none Devices: none. Glucometer at home, fasting 7–8. Recently stopped: none. Discrepancies: EMR still lists hydrochlorothiazide 25 mg — patient and pharmacy say stopped 2024 for low Na. EMR missing empagliflozin (started endocrinology 2025) and hydromorphone (GP, 2024). Cannot confirm: exact hydromorphone weekly count — patient estimates 8–10 tabs/week. Action: update EMR; flag SGLT2 hold; NSAID/ibuprofen counselling with ramipril; opioid listed for anesthesia.
Hand-off to discharge med rec
Admission BPMH is the baseline the discharge summary must compare against. If the inpatient list never included the home puffer, the discharge letter will not restart it. Keep OTC and devices on the same form so anesthesia, pharmacy, and the GP see them. When you cannot confirm a drug, say so on the discharge med rec rather than dropping the line.
Dictate the med list from the bottles
Scribeberry can turn a medication interview into a structured list in your BPMH headings. You still check high-alert drugs against pharmacy data. Smart Push into Accuro, OSCAR, Jane, or any web EMR. Pro is $99/month after the free trial.
Frequently asked questions
What is a best possible medication history?
A BPMH is a systematic med list built from more than one source — typically the patient, vials or dosette, and pharmacy or a provincial drug system — including OTC, herbals, inhalers, injections, and relevant devices. It is the baseline for admission and discharge reconciliation.
Should OTC and vitamins be on the medication list?
Yes, if the patient uses them. NSAIDs, iron, St. John's wort, and high-dose vitamin E change bleeding, interaction, and peri-operative risk. A list of prescriptions alone is incomplete.
How do I document a medication I cannot confirm?
Keep a 'cannot confirm' line with what you know and why (two pharmacies, no vials, patient unsure of dose). Do not delete it to make the list look clean, and do not invent a strength.
Can Scribeberry produce a medication list from the visit?
Yes. Use a BPMH template, record the med interview or dictate from bottles, and generate. Reconcile against pharmacy information before you sign, especially for anticoagulants, insulin, and opioids.
Templates
