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Medication reconciliation

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  • 1. Medication ReconciliationMedication Reconciliation is the process of comparing a patient’sbest-known list of current medications against the physician’sadmission, transfer, and/or discharge orders This process serves to minimize medication errors, includingomissions, duplications, or drug interactions. Sources for obtaining the most accurate medication list possiblewhen the patient and/or family are not considered to be a reliablesource of information include: • Transferring or discharging facility • Primary care physician office record • Previous hospital records • Patient’s pharmacy
  • 2. Medication Reconciliation: Admission The ED nurse documents the patient’s current medications in the ED electronic health record. The list includes medication name, dosage/strength, route, and date/time of last dose The emergency department medication list may be used by the admitting nurse as a baseline to verify the accuracy of the patient’s home medications a second time. However, the ED list shouldn’t be used without other verification. A list of the patient’s home medications is documented in CPSI via the Medication Reconciliation: Home Med List eform. It includes the medication name, dosage/strength, route, and date/time of last dose. This list is printed and placed under the H&P tab on the chart. This is done for outpatients, observation patients, and inpatients
  • 3. Medication Reconciliation: Admission (cont)  The Medication Reconciliation: Admit Orders eform is printed and placed under the physician’s orders section of the chart  Lock this eform before printing because this is an actual physician order sheet. Every effort will be made to keep the form on top of the most current order sheet until addressed by the physician  The physician reviews the home med list with any medications ordered since arriving to WCMC, and checks the box to either continue or discontinuing each home medication
  • 4. Medication Reconciliation: Admission (cont) All inpatients will have medications reconciled by the physician within 24 hours of admission. • However, if there are medications where missing or delaying a dose might present a higher risk to the patient, the nurse can notify the physician and obtain a telephone/verbal order for completing the admission Medication Reconciliation process . If the list of the patient’s home medications needs to be amended after the initial medication reconciliation, the correct information should be entered on the Home Medication List eform, and the doctor notified of the corrected information.  If the doctor wants the corrected home medication to be given to the patient, an order is written for the new or changed medication.
  • 5. Medication Reconciliation: Admission (cont)These medications are brought to the attention of the physician for amedication order prior to the next scheduled dose and include thefollowing medication categories:  Antibiotics  Inhalers  Insulin  Antiseizure medications  Oral hypoglycemics  Ophthalmic medications  Antihypertensives  Pain medications  Antiarrhythmics  Antianginal medications  Anti-rejection medicationsHome medications that require administration to the patient prior toreconciliation by the physician are written on a separate order sheet as averbal or telephone orderThe home medications are updated with any new information throughoutthe hospital stay even if the admission medication reconciliation has beencompleted by the physician
  • 6. Medication Reconciliation: Post-OperativeBefore the patient goes to surgery, nursing services prints thePhysician Order Report (for medications) and places in the physicianorder section of the chartThe surgeon verifies additions or deletions to be made to thepatient’s current medications by checking the appropriate box on thereport to either continue or discontinue each medication listed andsigning/dating the reportOR personnel will stamp “Post-Op” on the Physician Order Report.The Physician Order Report is faxed to the pharmacy as a physicianorder
  • 7. Medication Reconciliation: DischargeMedication reconciliation upon discharge is performed withspecial attention devoted to: •Medications required for the patient’s pre-admission chronic ailments •Medications for newly diagnosed clinical conditions •Prevention of therapeutic duplication/drug interactionsFor inpatients, the Physician Order Report (for medications) isprinted from CPSI by nursing services and placed in the physicianorder section of the chart for the physician to review prior topatient discharge. (NOTE: This report is a list of all activemedications and will not list any home medications that weren’tcontinued during the hospital stay)
  • 8. Medication Reconciliation: Discharge (cont)The physician will review the Physician Order Report for decisionto either continue or discontinue all medications listed on thereport by checking the appropriate box on the form andsigning/dating the form The physician will also review the Home Medication List under theHistory and Physical tab on the chart in order to reconcile any homemedications that may have changed or that were not continuedduring the hospital stayNOTE: These medications will not be displayed on the PhysicianOrder ReportAny prescriptions are written on the Physician’s Order sheet withthe rest of the discharge orders
  • 9. Medication Reconciliation: Discharge (cont)At Discharge;The Physician Order Report serves as the physician’sdischarge medication orders OR the physician may choose to write out the reconciled listof medications the patient is to continue after discharge NOTE: It is not an acceptable policy for the physician touse the 24 hour summary to check which medications hewants continued after discharge. This page is not acomplete list of all medications, and the 24 hour summaryis not considered a part of the permanent record
  • 10. Medication Reconciliation: Discharge (cont)Nursing must verify that all home medications and activemedications are addressed by the physician in order to providethe patient with a complete reconciled discharge medicationlistNursing must notify the physician of any medications (homeor active) that he did NOT order to be continued ordiscontinued after dischargeAfter all medications are reconciled, the nurse provides a listof discharge medications on the Discharge Instructions EformThe patient is instructed to take the Discharge Instructionsand Medications List as well as their medication bottles to theirnext appointment with their physician or caregiver

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