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Medication Reconciliation Process

Medication Reconciliation Process. “Go Live” date at SAH is 09/01/2008. Medication Reconciliation. This new process will: Improve patient safety Largely eliminate transcription, reducing time spent on discharge, and transcription errors Increase Core Measure compliance

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Medication Reconciliation Process

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  1. Medication Reconciliation Process “Go Live” date at SAH is 09/01/2008

  2. Medication Reconciliation This new process will: • Improve patient safety • Largely eliminate transcription, reducing time spent on discharge, and transcription errors • Increase Core Measure compliance • Increase JCAHO compliance (If you also practice at SDMC, NAMC, or RRMC, you may already be familiar with this process.)

  3. Medication Reconciliation- Admission process

  4. Medication Reconciliation- Transfer Process

  5. Medication Reconciliation- Discharge Process

  6. Current/Discharge Medications Reconciliation Form- example of form with home and inpatient medications

  7. Current/Discharge Medications Reconciliation Form-example of formwith home medications only

  8. Current/Discharge Medications Reconciliation Form-Example of form without home or inpatient medications

  9. Medication Reconciliation- Physician Responsibilities • For admissions, transfers to another level of care, or discharges: • Review the patient’s medications on the Current/Discharge Medication Reconciliation Form; • Indicate ‘Yes’ to continue the medication or ‘No’ to discontinue it; • Write medication edits or additions at the bottom under the ‘Additional Medications’ heading; • Sign the form. • The patient’s current and home medications may be reviewed using this form at any time during the hospitalization. The form will be updated nightly and filed in the ‘orders’ section of the chart. • It is not necessary to sign the form daily. The only time a signature is necessary is when the form is being used for admission, transfer to another level of care, or discharge as noted above.

  10. Medication Reconciliation-Physician Responsibilities- ED Admissions • ED Admissions: • If a patient admission history has been completed by the admission nurse, the ‘Current/Discharge Medication Reconciliation’ form will be printed and placed on the chart for the physician to review and sign when writing admission orders. • If the admission history has not been completed, the physician should review the list of home medications provided through ED T-systems. • If the ‘Current/Discharge Medication Reconciliation’ form is not available on admission, the admitting physician may sign the form the next time they round on the patient. The admitting medication orders may be written on a Physician Order form.

  11. Medication Reconciliation- Points to Watch • Some medications may be listed twice on the Current/Discharge Medication Reconciliation form. Once under the Home Medications section and once under the Scheduled Medications section. When discharging the patient, be aware of doses that may not match. (i.e., Dosage was changed in the hospital - ASA 81 mg po daily at home, ASA 325 mg po daily in hospital) • When discharging the patient, please assure that all new prescriptions have been added to the Current/Discharge Medication Reconciliation form under the Additional Medications section. • Please write legibly and clearly on this form. The patient is given a copy to take home and nursing has been instructed to call physicians for clarification of illegible orders.

  12. Medication Reconciliation- discharge • Part of the JCAHO requirement is that the patient’s discharge medications are communicated to their Primary Care Provider at discharge. • Core Measure Heart Failure guidelines state that the discharge medications listed on the Discharge Summary must match the discharge medications ordered. To achieve core measure medication reconciliation compliance, SAH is asking the discharge physician to note “Refer to ‘Current/Discharge Medication Reconciliation form” under the Discharge Medications section of the Discharge Summary instead of dictating each medication. SAH will then fax the form to the next provider of care. Beginning Sept. 1st,physicians who have an office practice will begin to receive faxes of these forms, in addition to the Discharge Summary.

  13. Medication Reconciliation • Questions? • Contact: • Kim Johnson, Director of Quality • Sandie Stevenson, Manager, Quality Outcomes • Chris Rodriguez, Meditech Analyst • Angela Smith, Leslie Mumy, Joan Minnick, Clinical Education Dept.

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