Medical Reconciliation and Documentation

1. Medical Reconciliationand Documentation

2. Definition • Medication Reconciliation is a process of obtaining a list of the patient’s current medications, including the name of the drug, dosage, route, frequency and time of last dose. • Medications must be reconciled upon admission, transfer within the hospital to another level of care, going to surgery, and at discharge.

3. Medical Reconciliation • A medication and allergy history is obtained by the medical provider from the patient and/or family members who are present at the time the patient presents for care, or at the time of admission. • The medication history should include a complete list of prescription and non-prescription medications: • Over-the-counter medications • Patches • Inhalers • Ear/eye/nose drops • Dietary supplements

4. Medical Reconciliation (cont.) • The medical provider should determine if the medication history is being obtained from a reliable source. • The patient’s current pharmacy • The patient’s physician’s office or clinic • The patient’s long-term care facility or home care records • Transfer forms from another facility • Recent hospital discharge forms • The source of the medication history must be recorded in the patient’s medical record.

5. When do you do Med Rec? • Once upon patient admission, to reconcile what he or she was taking, • Again when ordering his or her meds, to reconcile what he or she is taking in the hospital, • And once more upon transfer and discharge, to reconcile what he or she will be taking.

6. Documenting HDS Usage • Use the same technique and detail as with medications. • This will include information about: • Constituents, plant species • Name of product • Brand, manufacturer • Dosage and duration • Frequency of use, when used • Purpose • Cost of each HDS used

7. Barriers to Medical Reconciliation and Documentation • Patient knowledge about medications limited • Electronic medical records • Fragmentation of care • Time constraints

8. End of Presentation