Electronic Medication Reconciliation

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Phelps County

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Electronic Medication Reconciliation

  1. 1. Electronic MedicationReconciliationPhelps County Regional Medical CenterKaren Clover, BSN, RNPam Karr, MSN, RN-BC
  2. 2. Patient’s Presentation Patient presents to the ED  Nurse obtains current medication list Available for viewing by ED physician
  3. 3.  Screen shot of what nurses review on admission
  4. 4.  Screen shot of ED med list
  5. 5. Patient admitted to facility Patient arrives to floor  Nurse reviews previous med list and confirms accuracy
  6. 6. Physician Reconciliation Screen shot
  7. 7. Patient transferred withinfacility Screen shot of physician’s med rec with transfer
  8. 8. Discharge Physician screen shot of d/c med rec
  9. 9. Phelps County Regional Medical Center Discharge Medication List / Discharge instructions Patient Name: Patient Joe Report Status: Signed Account Number: Report Number: 0525-0024 Attending Physician: PLEASE KEEP THIS LIST BRING IT WITH YOU IF/WHEN YOU MUST RETURN TO T***NOTE: Patients and families are reminded to discard old lists and to update any records with all medication p Discharge Instructions ALLERGIES Coded Allergies: IVP Dye (Severe, ANAPHYLAXIS 04/01/11) Penicillins (05/17/11) PRESCRIPTIONS Continue taking these medications: Norvasc (Amlodipine Besylate) 10 MG TAB 10 MILLIGRAM ORAL Daily Prilosec (Omeprazole) 20 MG CAPDR 20 MILLIGRAM ORAL Daily Synthroid (Levothyroxine Sodium) 75 MCG TAB 75 MICROGRAM ORAL Daily Caltrate-600 With Vit D Tab (Calcium Carb/Vit D3/Minerals) 1 TAB TABLET 1 TAB ORAL Daily Omega 3 Fish Oil 1,000 Mg Cap (Omega-3 Fatty Acids/Fish Oil) 1 CAP CAPSULE 1 CAPSULE ORAL Two Times A DayTylenol (Acetaminophen) 325 MG TAB 650 MILLIGRAM ORAL Q6H PRN :Start taking the following new medications Vicodin 5 Mg/500 Mg (Hydrocodone-Apap 5 Mg/500 Mg) 1 TAB TAB 1 - 2 TAB ORAL As Needed Discharge Instructions DIET: Regular DIET RESTRICTIONS: None SPECIAL INSTRUCTIONS: None WOUND/SKIN CARE: [may shower in the am]ACTIVITY RESTRICTION: no lifting over 20 pounds for two weeks FOLLOW-UP CARE: Follow up with Dr. Wilcox in 10 days
  10. 10. Challenges Patient’s ability to recall medications, dosage, and frequency Interviewer’s skill level Time constraints Accessibility during nights/weekends for confirmation of med list Multiple Providers
  11. 11. Challenges Language barriers/cultural beliefs Stress of transitioning through healthcare system Accuracy and completeness of medical history obtained from other resources Communication of incomplete home medication list
  12. 12. Newest Challenge Transitioning to paperless electronic record Complexity of electronic health record Compliance with provider to use electronic medication reconciliation Efficient up dating of medication record

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