Standards › Standard S4 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · LTC-SOP-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: System S4 (Long-term care), criterion S4.4
At a glance
- Compare the resident’s own medicines with the home’s list at admission, transfer and discharge.
- Resolve every difference with the prescriber before the next dose.
- Record the result on the reconciliation form.
- Give the resident and the next provider a single current list.
- Stop and get help straight away if: a dose is given or stopped on a change of care without a reconciliation being recorded.
1. Purpose
To stop medicines being missed, doubled or stopped by mistake when a resident moves between care settings (S4.4).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
A patient’s own medicines are often changed or missed at admission and discharge. A reconciliation at each change is the safest way to catch this.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Registered nurse | Carries out the reconciliation and speaks to the prescriber | Registered nurse |
| Prescriber | Confirms or changes each difference | Doctor or nurse prescriber |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Collect the list.
- Get the resident’s own medicine list from the discharging or admitting provider, the pharmacy and the resident or family.
Key point: Three sources are better than one.
Step 2. Compare.
- Compare each medicine on the list with the home’s list.
- Mark each difference: missing, changed, extra or duplicate.
Key point: Every difference is a question.
Step 3. Resolve.
- Ask the prescriber about each difference before the next dose is due.
- Record the decision and who made it.
Key point: No difference is left open.
Step 4. Give the current list.
- Give one current list to the resident, the family and the next provider.
Key point: One list, shared.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Changes of care with reconciliation recorded | 100% | Monthly | Nurse in charge | Escalate to clinical lead |
| Differences resolved before the next dose | 100% | Monthly | Clinical lead | Escalate to chief executive |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| LTC-FRM-002 | Medicine reconciliation form | Form |
| HOS-POL-001 | Medicines policy | Policy |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO High 5s medication reconciliation standard operating protocol (2014). |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
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References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)