Medication Reconciliation Policy and Process

1. Medication Reconciliation Policy and Process Start

2. Medication Reconciliation is a standardized process whereby the most complete and accurate list possible of a patient’s medications is communicated to the next provider of service. Next

3. Time of Admission Medication Reconciliation occurs at: Next Change in level of care Upon Discharge

4. Time of Admission Typically, the first step of the admission medication reconciliation involves the compilation of a complete and accurate list of medications the patient is currently taking at home. The blue circle with exclamation mark icon next to Meds History indicates that no Medication History has been completed during this visit. Next

5. Time of Admission Unless previously documented for the patient’s current visit, a Medication History should be obtained upon first contact with the patient. • In most cases, patients in the ED will have a med history obtained by the primary nurse or pharmacy. • Direct floor admits will have a med history completed by the admitting physician. The meds history for this patient can be completed by starting here. Next

6. Documented medications for the patient are listed. To document medication history: • If no meds are listed and the patient states he/she does not take any medication, click on the No Known Home Medications checkbox, then click Document History button. • If meds are listed and patient states there are no additional meds, click the Document History button. • If a med the patient is taking is not listed, click on the +Add button to add the med to the list. • If the patient states they are no longer taking a med, right-click on the med and REMOVE the med from the patient’s list using Cancel/DC or Complete. Document Medication by Hx Next

7. Use the Add Order window to search for the name of the patient’s medication. • Note that the medication is being entered as a historic med and will display on the Med List with a scroll icon next to the medication name. Document Medication by Hx Next

8. In the Document Medication by Hx window, add any medication the patient is taking and remove any medication the patient is no longer taking. • Once all medications have been added/removed, click on the Document History button. Document Medication by Hx Next

9. Once the medication history is documented, the Status bar changes to show a green checkmark next to Meds History. Document Medication by Hx Next

10. The next step in the admission process is the Admission Meds Reconciliation. The Admitting Provider will complete the Admission Medication Reconciliation in EMR by indicating which medications will be continued without changes, continued with changes, or not continued during a patient’s visit within 24 hours of admission to a UMHC Facility. From either the Orders or Medication List window, click on Reconciliation and select Admission from the menu. Admission Meds Reconciliation Next

11. As the admitting provider, you must decide if the patient will continue any home medications as an inpatient by selecting Continue or Do Not Continue. Remember, in this window you can also modify dose, route, and frequency on any med you choose to continue. Admission Meds Reconciliation Next

12. After deciding which medication(s) to continue during the patient’s hospitalization, click the Reconcile And Sign button. Admission Meds Reconciliation Next

13. After completing the Admission Meds Reconciliation, a green checkmark appears in the Status field next to Adm. Meds Rec. Admission Meds Reconciliation Next

14. If you are right-clicking on the patient’s listed medications and selecting Convert to Inpatient Order, you are NOT doing Admission Meds Reconciliation and will never receive a green checkmark next to Adm. Meds Rec in the Status. This is a conversion of medications and not a meds reconciliation. Admission Meds Reconciliation Next

15. After documenting the Meds History and the Admission Meds Reconciliation, complete admit orders (PowerPlan) for the patient. The admit orders PowerPlan includes inpatient medication orders generally used on your service. Next

16. Change in level of care Inpatients transferred to another level of care shall have their medication list reviewed by the transferring physician, indicating which medications are to be continued without modification, modified, or discontinued. • Refers to the transfer of patients into or out of intensive care or Step-Down-Unit, or change in primary service. • The Transfer Medication Reconciliation function in the EMR is utilized for documentation of medication reconciliation at the time of transfer in level of care. • The transferring provider is responsible for completion of the Transfer Medication Reconciliation and submission of these orders along with any other needed transfer orders. Next

17. To complete the Transfer Medication Reconciliation, click on the Reconciliation button and select Transfer from the menu. Transfer Meds Reconciliation Next

18. The Transfer Meds Rec screen lists all medications documented for the patient. Any medication ordered upon admission is shown with the Continue circle selected. Select either Continue or Do Not Continue for each med listed based on the needs of your patient. Transfer Meds Reconciliation • Note the multivitamin displays with an orange circle/asterisk next to the order name. This indicates a home med not continued as an inpatient order upon admission. • A selection must be made whether to Continue or Do Not Continue the multivitamin upon transfer, before signing the reconciliation. Next

19. After selecting which medications will be continued after the transfer, click on the Reconcile and Sign button to complete the Transfer Medication Reconciliation. You can also modify dose, route, and frequency on any med you choose to continue or add additional meds. Transfer Meds Reconciliation Next

20. Remember to complete any other transfer orders needed at this time. Transfer Meds Reconciliation Next

21. The Status field does not have an indicator for Transfer Meds Rec. If you are not sure if the Transfer Meds Rec has been completed, look at the Reconciliation History in the View section of the Orders screen. The date, time, and name of the provider who completed the reconciliation appear under the Reconciliation History. Transfer Meds Reconciliation Next

22. A return of a post-operative patient to a unit is considered a change in level of care, except in a few specific situations: • If patient went to the OR multiple times for the same procedure. • If patient is having a sequence of planned surgical procedures, without any associated significant changes in clinical status. The physician completing the post-operative orders is responsible for completion of the Transfer Medication Reconciliation and the submission of these orders, along with other needed post-operative orders. Transfer Meds Reconciliation Next

23. Nurses will suspend all active inpatient medication orders for patients going to the OR, radiology, or cardiac catheterization laboratory. • If the patient’s surgery/procedure is postponed for any reason, the nurse is to reinstate the suspended orders as “written” communication type. Transfer Meds Reconciliation - Pre Op Next

24. After surgery/procedure, the physician will complete Transfer Medication Reconciliation. The Transfer Medication Reconciliation process allows the physician either to “resume” (Continue) or “discontinue” (Do Not Continue) pre-surgery/procedure medications. Transfer Meds Reconciliation - Post Op Next

25. Upon Discharge Medication reconciliation will be accomplished on all inpatients and 23 hour observation patients at the time of hospital discharge, with this process documented by the discharging physician using the EMR. • For inpatients, providers will complete this process as they create the Depart Summary. • Providers should be aware that when performing Discharge Medication Reconciliation, they will be prompted to review both previous home medications and current inpatient medications, indicating which of these should be taken by the patient following discharge. Next

26. Discharge Meds Reconciliation During the completion of discharge EMR documentation, newly implemented changes to the patient’s previous home medication regimen will be indicated on the patient’s home medication list in the EMR by the discharging provider. This final updating of the medication list prior to discharge allows for printing of an accurate discharge medication list for the patient as part of the Depart Summary, and ensures that the EMR will be up-to-date at the time of the follow-up outpatient visits or at the time of subsequent inpatient readmissions. Next

27. Discharge Meds Reconciliation Discharge Meds Reconciliation can be performed from either the Orders screen, the Medication List screen, or the Depart window. Next

28. Discharge Meds Reconciliation From the Depart Process window, Medication Reconciliation is a required step in the discharge of a patient. Click on the pencil icon to open the Discharge Meds Reconciliation window. Next

29. Discharge Meds Reconciliation The Discharge Meds Reconciliation window lists the patient’s home historic medications, prescriptions, inpatient medications, and IV solutions. Select which medications to Continue After Discharge, Create New Prescription, or Do Not Continue After Discharge. Next

30. Discharge Meds Reconciliation After reconciling all of the medications listed for the patient, click the Reconcile and Sign button to complete the Discharge Medication Reconciliation. Additional discharge prescriptions may be written at this time from this screen. Next

31. Following completion of EMR documentation, staff will print out the discharge medication documentation as part of the Depart Summary and provide it to the patient. The patient’s nurse or other clinical staff (ie. Pharmacists or physicians) will review the list of medications with the patient and provide education about the new home medication regimen. Next

32. Reconciliation of medications is required at all outpatient visits during which a prescriber may potentially order a new medication or change an existing medication for a patient. • Examples of outpatient appointments at which medication reconciliation would normally be required are: • Routine outpatient care visits • Emergency room visits • Ambulatory surgery visits during which new home medications are ordered • Urgent care visits Outpatient Visits Next

33. Medication Reconciliation is not required for: • Simple lab or X-ray procedures • Therapeutic radiation with no medication issues • Vaccine administration only • Allergy injection only • Outpatient encounter for procedure that does not affect patient’s home medication regimen • Nurse blood pressure check Outpatient Visits Next

34. Upon presentation for an outpatient visit in which medication reconciliation is required, the patient will be presented with a list of their known home medications printed from the EMR. • The patient will be asked to review the list and note any discrepancies. • The medication list in the EMR will then be updated by clinical staff to match patient’s medication use. Outpatient Visits Next

35. How a medication is removed from a patient’s medication list determines the section of the Depart Summary in which the medication appears. What causes a medication to be listed or not listed in a particular section? • The NEW, CHANGED or REFILLED list: • Contains ONLY those active medications listed as PRESCRIPTIONS in the Medication List that were ADDED, MODIFIED, or REFILLED on the current visit. • The CONTINUE TAKING list: • Contains ALL medications listed as Historical Medications in the Medication List. • Contains any PRESCRIPTIONS from previous visits that were continued without changes. • The STOP TAKING list: • Contains ANY medication (historical or prescription) ordered on a previous visit that was DISCONTINUED during this visit. • Prescriptions that CHANGED during a refill or reorder process MAY generate an entry to this list. • COMPLETED medications will not be listed. Outpatient Visits Next

36. At the completion of the outpatient visit, the health care professional will note any additions, deletions, or amendments to the Medication List in the EMR. • A copy of the updated home medication list will be provided to the patient at the time of their discharge from the outpatient clinic in the Depart Summary. Outpatient Visits Next

37. UH EMR Training and Support Room (1W36) 884-0728 • WCH EMR Training and Support Room (1251) 875-9378 • Tiger Power Support wiki (MyApps) • Docushare policy MM-13 Medication Reconciliation Additional information on medication reconciliation can be found at: Exit