Recurring concern
Inadequate recording of medication prescribing decisions
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Request correctionFirst reported 21 Mar 2014•Latest report 27 Oct 2025
What this concern includes
Includes deficiencies in records supporting medication prescribing, including recording the rationale for stopping a medicine, cancelling discontinued prescriptions, accurately classifying repeat and acute prescriptions, recording externally requested medicines, and clearly displaying prescription chronology or quantities.
Not included
- Excludes generic deficiencies in basic clinical record keeping that are not specifically tied to medication prescribing.
- Excludes medication administration deficiencies where the prescribing record is not the unsafe control.
- Excludes failures to monitor a named medication hazard when the record-keeping deficiency is not part of the medication prescribing process.
- Excludes generic communication, staffing, training or investigation failures unless they directly concern the reliability of medication prescribing records.
- Reports
- 28
- Individual concerns
- 29
- Date range
- 2014–2025
- Stated actions
- 29
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
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Concerns raised1
Failure to record clinical rationale for continued repeat prescribing in light of overdose risk
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Amend the self-harm follow-up policy to require medication review and consideration of reducing prescription quantities where ongoing risk exists.
Stated by Your Health Partnership PCN -
Action
Amend the self-harm risk-assessment template to record medication review discussions, stockpiling, medication safety, prescription quantity, and medication supervision options.
Stated by Your Health Partnership PCN
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Concerns raised1
Failure of the Medication Record to record medication prescription times
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Implement completion of an actual administration time on Emergency Department medication cards and prohibit recording “stat” for intravenous antibiotics.
Stated by Hywel Dda University LHB -
Action
Implement electronic prescribing and medicines administration systems across Welsh hospitals, with timestamped prescribing and administration records and medication task lists.
Stated by Welsh Government
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Changes to the nationally approved Emergency Department medication chart must be considered by the national group, not unilaterally by the Health Board.
Stated by Hywel Dda University LHB
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Position
Existing ARK chart features provide mechanisms to record administration times for urgent and scheduled medicines.
Stated by Welsh Government
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Concerns raised1
Failure to record medication tapering regimes in clinical notes
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Action
Communicate and reinforce the requirement that medication tapering regimes are recorded in notes and scanned into electronic patient records.
Stated by Mid and South Essex NHS Foundation Trust -
Action
Audit neurology clinic records for record-keeping compliance and conduct quarterly reviews for divisional governance assurance.
Stated by Mid and South Essex NHS Foundation Trust -
Action
Conduct a GIRFT review visit to Mid and South Essex NHS Foundation Trust’s neurology department.
Stated by NHS England
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Many concerns about Chloe’s care fall within the NHS Foundation Trust’s remit rather than NHS England’s national programme or policy remit.
Stated by NHS England
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Concerns raised1
Possible deficiencies in record keeping for Pregabalin prescriptions
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Document medication dose or tablet-strength changes and notify patients of those changes.
Stated by Limehouse Practice -
Action
Provide all prescribers with refresher training on EMIS medication history and prescribing dependence-potential medicines.
Stated by Limehouse Practice
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Concerns raised1
Failure to clearly record prescribed medication strength and administration volume
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Discuss liquid morphine safety with London ICB medication-safety representatives and provide regional oversight of action-plan implementation, including communications to GPs and community pharmacists.
Stated by NHS England
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Concerns raised2
Failure of EMIS prescription records to clearly display the chronology of issued prescriptions
Failure of ended repeat prescriptions to be removed from pending medication-management queues
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Action
Provide medication views that display prescriptions chronologically by last issue date and allow clinicians to configure grouping.
Stated by EMIS Group -
Action
Provide Drug History functionality showing medication commencement, modification, ending, and issue-request events.
Stated by EMIS Group -
Action
Maintain cancellation warnings, workflow task visibility, and restart-or-reject controls for ended repeat prescriptions.
Stated by EMIS Group
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Existing EMIS Web functionality is sufficient to mitigate the identified medication-management risks, so no software developments are required.
Stated by EMIS Group
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Concerns raised1
Failure to identify the prescribing doctor and record prescribing decision-making
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The records identify the prescriber and document the rationale for suspending aspirin and prescribing dalteparin.
Stated by Royal Cornwall Hospitals NHS Trust
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Concerns raised1
Failure of the prescribing system to record discontinued Oromorph prescriptions
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Investigate how primary-care morphine changes were recorded, communicated and reflected in the Kent Summary of Care Record.
Stated by Medway NHS Foundation Trust
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Concerns raised1
Inadequate recording of clinical factors supporting enoxaparin prescribing
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Lack of a central record of issued prescriptions
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Action
Fund and support electronic prescribing adoption across NHS trusts, including the remaining trusts.
Stated by NHS England -
Action
Define common medicines-information standards and support their adoption across health and care organisations.
Stated by NHS England -
Action
Deliver minimum shared-record view access to currently digitally available medicines information.
Stated by NHS England
Data last updated 7 September 2026