A discussion of the provincial transfer/discharge medication reconciliation form from acute care facilities. We will discuss the form in the current state and the purpose of the form when presented to community pharmacies across the province. This discussion will help gain an understanding of the patients “story” of medications utilized prior to admission to hospital, what medications were utilized in hospital and what medications the patient is to continue after discharge. The session will help community pharmacists understand what medications are to be dispensed from the form. The understanding of the use of the form will allow community pharmacies to provide a continuity of care of the patient in the transition from an acute care facility to their community home.

1. Saskatchewan Transfer-
Discharge Medication
Reconciliation
Presented by
Rhonda Pearce BSP Clinical Informatics Specialist
eHealth Saskatchewan
Kim Borschowa BSP Director of Pharmacy Weyburn
General Hospital

2. MedRec at Discharge & Transfer in
Acute Care
• The DTMR is a professional document utilized by
health care professionals for discharges and/or
transfers from acute care settings across the
province. The purpose of the form is to provide a
complete picture of a patient’s medication at from
an acute care visit.
• The form has been created by the Provincial Med
Rec group that consists of health care professionals
across the province- nurses, pharmacists, physicians,

3. • In 2017, eHealth began the implementations of the
provincial BDM software solution across the
province within it’s hospitals.
• With these implementations came the opportunity
to host the Ministry of Saskatchewan’s DTMR form
within the vendor software. This allows for the
patient’s information and medications to
autopopulate from the patient profile based obn
status within BDM.
• The form has been utilized across the province as
the implementations concluded in December 2018.

4. • All of the hospitals in Saskatchewan are provincially
hosted by eHealth Saskatchewan with the exception of
the former Regina-Qu’appelle Health Region.
• Regina Qu’appelle does have access to this form within
their BDM version.

5. Steps to Complete the DTMR
The form is completed when movement of a patient has
been initiated.
1) List the active meds in Section 1 and the stopped/held
medications in section 2
2)Compare the list of active meds in section 1 to the
BPMH(best possible medication history from PIP and patient
interview during hospital stay)to confirm the list is complete.
Check each medication for the status and
rationale/background information if applicable

6. Compare the list of stopped/held medications at admission
in section 2 to the BPMH for completeness and document
relevant information
3)Prescriber reviews all sections, resolves discrepancies and
orders medications with quantity and refills specified in all
sections including medications to start after discharge
4)Confirm the form is complete and document any
discrepancies to be reconciled.
5)Once signed by the prescriber the form is sent with the
patient or faxed to their community pharmacy as a
prescription.

7. Understanding the DTMR Form

8. Understanding the DTMR Form
•

10. Understanding the DTMR Form

14. The Good

19. The Ugly

20. The Real World

21. April 30, 2018
Antibiotic written for 7 days (until May 2) but the physician
has checked “stop” …..
What would you do?

22. Your profile shows the patient on vitamin D 2000 units daily
in the morning.
This is what you receive from the hospital on discharge……….
What would you do???

23. Your profile shows the patient is taking ramipril 2.5 mg daily in
the morning.
The discharge med rec you receive from hospital does not list
ramipril as a medication the patient was given while in hospital.
Pre-admission medication section of the form looks like this.
What would you do???

24. Its Friday evening and this is the discharge you receive from the
hospital.
The physician is unavailable by phone.
Your patient has been taking these medications for years and had
no refills remaining on their profile.
They present you with this……. What would you do???

25. It is Sunday morning and you receive this from your patient’s daughter. The physician is
not available, the daughter knows nothing about her mother’s hospital stay. There is no
one in the pharmacy department at the hospital that you can call because they do not
work weekends. You call the ward but there are a new shift of nurses working that did
not care for this patient and the chart is gone. The patient has never taken this
medication before.
What would you do???

26. The antibiotic says “for 7 days” but the physician has checked continue , 1/12 and 3
refills for all these meds……………
What would you do???