Medication Register — Roots to Recovery

This Register is maintained for each Resident from the date of admission to the date of discharge. It records every medication brought onto the premises, every pharmacist-packaged weekly compliance pack issued, every medication change, every missed dose reported, every medication-related incident, and the disposal or return of any medication on discharge or expiry.

The Register must be completed contemporaneously by the staff member on duty. Entries must be made in indelible ink. Errors must be struck through with a single line, initialled and dated, and the corrected entry recorded alongside.

RESIDENT IDENTIFICATION

Full NamesIdentity Number / Passport NumberDate of AdmissionRoom AllocatedMedical Aid Scheme and NumberAllergies (medication and other)Chronic Conditions Relevant to MedicationTreating Practitioner (Name and Contact)Appointed PharmacyPharmacist (Name and Contact)

PART A — MEDICATION RECEIVED ON ADMISSION

Every container of medication brought onto the premises on admission, whether prescription, over-the-counter, natural remedy, supplement or homeopathic preparation, must be recorded in the table below and handed to the Facility for safekeeping.

Medication Name	Strength	Form (tablet/syrup/etc.)	Quantity Received	Expiry Date	Container Sealed (Y/N)	Received By (Staff)	Resident Sign	Date

PART B — CURRENT PRESCRIBED MEDICATION

Record every medication currently prescribed for the Resident. Update the table as new medication is added or as existing medication is changed or discontinued. Mark each line as Active, Suspended or Discontinued, and date the change.

Medication	Strength	Dose & Route	Frequency	Indication	Prescriber	Start Date	Status	Date of Status Change

PART C — WEEKLY COMPLIANCE PACK ISSUE

Weekly compliance packs are prepared by the appointed pharmacy and issued to the Resident on a Sunday. Each issue must be witnessed by a second staff member. The Resident must sign on receipt.

Date Issued	Pack Reference	Contents Verified Against Script (Y/N)	Issued By (Staff)	Witnessed By (Staff)	Resident Signature	Return of Previous Pack (Empty / Partial / N/A)

PART D — MEDICATION CHANGES

Record every change to the Resident's medication regime, including new prescriptions, dose adjustments, brand changes, suspensions and discontinuations. Note the prescriber and the reason for the change.

Date of Change	Medication	Nature of Change	Reason	Prescriber	Pharmacist Notified (Y/N)	Resident Notified (Y/N)	Responsible Person Notified (Y/N)	Recorded By (Staff)

PART E — MISSED, REFUSED OR LATE DOSES

Record every reported missed, refused or late dose. The Facility does not administer medication. Residents self-administer from the weekly compliance pack. This part records reports made by the Resident, observations by staff, or information disclosed by the pharmacist on review of returned packs.

Date	Time	Medication	Dose	Missed / Refused / Late	Reason (if disclosed)	Action Taken	Recorded By (Staff)

PART F — MEDICATION-RELATED INCIDENTS

Record any adverse reaction, side-effect, suspected misuse, suspected diversion, accidental ingestion, overdose or any other medication-related incident. A separate Incident Report Form must also be completed.

Date	Time	Medication	Nature of Incident	Immediate Action Taken	Practitioner Contacted	Resident Outcome	Recorded By (Staff)

PART G — SCHEDULE 5 AND SCHEDULE 6 MEDICATION (CONTROLLED)

Schedule 5 and Schedule 6 medications are subject to additional controls. Every container is counted on receipt, on each weekly pack issue, on each return, and on disposal. Counts must reconcile. Discrepancies must be investigated immediately and reported to the pharmacist and the Facility Manager.

Date	Medication	Strength	Opening Count	Received	Issued	Returned	Closing Count	Reconciled (Y/N)	Staff 1 Sign	Staff 2 Sign

PART H — DISPOSAL AND RETURN OF MEDICATION

Record the disposal of expired medication, the return of medication to the pharmacy, the return of medication to the Resident on discharge, and the destruction of any medication that cannot be returned.

Date	Medication	Quantity	Reason (Expired / Discharge / Return / Other)	Method of Disposal or Recipient	Witness (Staff)	Authorised By

PART I — DISCHARGE MEDICATION HANDOVER

On discharge, complete the handover record below.

Date of DischargeMedication handed back to the Resident (list all)Medication handed to the Responsible Person (list all)Medication returned to the Pharmacy (list all)Medication destroyed on the premises (list all and method)Resident SignatureResponsible Person Signature (if collecting medication)Staff Member SignatureWitness Signature

PART J — MONTHLY AUDIT

The Facility Manager, or delegate, reviews the Medication Register monthly to confirm accuracy, reconcile schedules and identify any patterns of concern.

Audit Date	Period Audited	Findings	Action Required	Auditor (Full Name)	Signature

RESIDENT ACKNOWLEDGEMENT

I, the Resident, acknowledge that:

I have disclosed all medication that I currently take and all medication that I have recently discontinued.
I will disclose any change in my medication immediately and in writing.
I will hand all medication received on admission, and any further medication brought onto the premises during my stay, to the Facility for safekeeping.
Pharmacist-packaged weekly compliance packs will be issued to me on a Sunday and I am responsible for self-administering my medication in accordance with the pharmacist's instructions.
The Facility accepts no responsibility for my compliance with my prescribed medication regime.
I will report any missed dose, side-effect, adverse reaction or medication-related concern to the staff on duty without delay.