Recurring concern
Inadequate recording of medication prescribing decisions
- Reports that mention this concern
- 28
- Times this concern has been raised
- 29
- Stated actions linked to this concern
- 29
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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 28 reports
See individual reports that have raised this concern, and the actions taken in response
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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.
Linked response
- Your Health Partnership PCN
Stated actions 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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Your Health Partnership PCN
Amend the self-harm follow-up policy to require medication review and consideration of reducing prescription quantities where ongoing risk exists.
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Your Health Partnership PCN
Amend the self-harm risk-assessment template to record medication review discussions, stockpiling, medication safety, prescription quantity, and medication supervision options.
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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.
Linked responses
- Hywel Dda University LHB
- Welsh Government
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
Hywel Dda University LHB
Implement completion of an actual administration time on Emergency Department medication cards and prohibit recording “stat” for intravenous antibiotics.
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Welsh Government
Implement electronic prescribing and medicines administration systems across Welsh hospitals, with timestamped prescribing and administration records and medication task lists.
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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Hywel Dda University LHB
Changes to the nationally approved Emergency Department medication chart must be considered by the national group, not unilaterally by the Health Board.
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Welsh Government
Existing ARK chart features provide mechanisms to record administration times for urgent and scheduled medicines.
-
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.
Linked responses
- Mid and South Essex NHS Foundation Trust
- NHS England
Stated actions 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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Mid and South Essex NHS Foundation Trust
Communicate and reinforce the requirement that medication tapering regimes are recorded in notes and scanned into electronic patient records.
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Mid and South Essex NHS Foundation Trust
Audit neurology clinic records for record-keeping compliance and conduct quarterly reviews for divisional governance assurance.
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NHS England
Conduct a GIRFT review visit to Mid and South Essex NHS Foundation Trust’s neurology department.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
NHS England
Many concerns about Chloe’s care fall within the NHS Foundation Trust’s remit rather than NHS England’s national programme or policy remit.
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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.
Linked response
- Limehouse Practice
Stated actions 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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Limehouse Practice
Document medication dose or tablet-strength changes and notify patients of those changes.
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Limehouse Practice
Provide all prescribers with refresher training on EMIS medication history and prescribing dependence-potential medicines.
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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.
Linked response
- NHS England
Stated actions 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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NHS England
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.
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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.
Linked response
- EMIS Group
Stated actions 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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EMIS Group
Provide medication views that display prescriptions chronologically by last issue date and allow clinicians to configure grouping.
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EMIS Group
Provide Drug History functionality showing medication commencement, modification, ending, and issue-request events.
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EMIS Group
Maintain cancellation warnings, workflow task visibility, and restart-or-reject controls for ended repeat prescriptions.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
EMIS Group
Existing EMIS Web functionality is sufficient to mitigate the identified medication-management risks, so no software developments are required.
-
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.
Linked response
- Royal Cornwall Hospitals NHS Trust
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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Royal Cornwall Hospitals NHS Trust
The records identify the prescriber and document the rationale for suspending aspirin and prescribing dalteparin.
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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.
Linked response
- Medway NHS Foundation Trust
Stated actions 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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Medway NHS Foundation Trust
Investigate how primary-care morphine changes were recorded, communicated and reflected in the Kent Summary of Care Record.
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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.
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.
Linked response
- NHS England
Stated actions 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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NHS England
Fund and support electronic prescribing adoption across NHS trusts, including the remaining trusts.
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NHS England
Define common medicines-information standards and support their adoption across health and care organisations.
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NHS England
Deliver minimum shared-record view access to currently digitally available medicines information.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026