Medication Reconciliation

1. Medication Reconciliation Reports Instruction

2. Medication Reconciliation Report • To complete the medication reconciliation report, check EITHER the box “CONT” to continue OR“STOP” to discontinue the home mediation.

3. Admission Home Medication Reconciliation Report

4. Admission HomeMedication Reconciliation Report • If you wish to continue the home medication on admission • Check “CONT” • If you wish to change the home medication on admission • Check “CONT” • Make the changes by clearly marking out text you wish to change and clearly writing the change you wish to make in the appropriate space on the form. • If you wish to discontinue the home medication on admission • Check “STOP” • This mean the specific home medication order will not be continued as inpatient medication.

5. Admission Home Reconciliation ReportTherapeutic Substitution • If a patient is on Lotrel 10/20 on Home Med list. • Check “CONT” Home Medication Lotrel 10/20. • Pharmacy will dispense per Hospital Formulary or clarify with you.

6. Discharge Home Medication Reconciliation Report

7. Discharge Medication Reconciliation Report Same Medication, Same Doses • When a medication is listed exactly the same under both “Home Medications” and “Active Pharmacy Medications”, • Check “CONT” the Home Medication and “STOP” the Active Pharmacy Medication. • DO NOT CONTINUE BOTH. • NOTE: If you check to continue both medications, you will be called for clarification.

8. Discharge Medication reconciliation Report Same Medication, Different Doses • When a medication is listed under both the “Home Medications” and “Active Pharmacy Medications”, but the dosage or frequency is different, • Check “CONT” the “Home Medications” and make the dosage/frequency changes on the Home Medications and • STOP” the Active Pharmacy Medication.

9. Discharge Medication Reconciliation Report Therapeutic Duplication • If a patient is on Lotrel 10/20 on Home Med list that was continued on admission, and Active Pharmacy Medication is 10/20 • If you wish the patient to continue with Lotrel 10/20, • Check to “CONT” the Home Medications 10/20. • If you wish the patient to increase the dose to Lotrel 10/40, • Check to “CONT” the “Home Medications”, cross out 10/20 and write 10/40. • “STOP” the “Active Pharmacy Medications” 10/20. • If you want the patient to start the new dosage Lotrel 20/40, • Check to “STOP” both “Home Medication” and “Active Pharmacy Medication”. Write a “NEW” order for 20/40. • NOTE: If you check to continue both the combination medication and either or both of the separate medications, you will be called for a clarification.

10. Discharge Medication Reconciliation Report Therapeutic Substitution • EXAMPLE: If the patient has an Aciphex 20 mg that was continued on admission, but therapeutically converted to Protonix 20 mg, the home medication list will have Aciphex and the active pharmacy medication list will have Protonix. •  Check “CONT” Home Medication Aciphex 20 mg (that is listed on the Home Medication section) and • “STOP” Active Pharmacy Medication – Protonix (that is listed on the active pharmacy medication section )

11. Discharge Medication Reconciliation Report New Discharge Medications • Write on the last page of the report in the ADDITIONAL MEDICATION ORDERS SECTION, or • On a separate order sheet attached to the Discharge Med Reconciliation Report.

12. Physician Signature • Initial each page of the Medication Reconciliation Report. • Sign, date and time the last page of the Medication Reconciliation Report.

13. FAQs

14. How is the Discharge Physician Med Rec List sorted? • It is sorted by drug class, then alphabetic by Generic • Some medications may fall into more than one drug class but will only list once. • Since medications may fall into more than one drug class; the side-by-side Med Rec list would not work. Cardiovascular Drugs Central Nervous System Agents

15. Why can’t we have the check off box for “Contact PCP on home medication” • To promote patient safety, physicians are required to reconcile all patient home medications on admission, transfer and discharge. • Medication reconciliation is defined as “Provide the patient (or family) as needed with written information on the medications the patient should be taking when he or she is discharged from the hospital or at the end of an outpatient encounter (e.g., name, dose, route, frequency, and purpose). • “Resume all home medications” or “Contact PCP on home medication” is not compliant with regulatory agencies standard.

16. Why are the OR/PACU medications printed on the Transfer/Discharge Physician Med Rec List? • All active medications for inpatients and outpatients are listed in the physician Med Rec Report. • There is a new Outpatient Report that can be used for outpatient and procedural areas.

17. Can Corporate gray out Active Med List when printing the report? • No, Corporate / Meditech has researched the issue. It is unable to gray out “Active Med List” • When printing Med Rec report, “Other Reports” must be checked off and click the drop down box to select one of the Med Rec reports.