- Medication reconcilliation (med rec) is not just a regulatory requirement but is an essential safety procedure. It ensures that the current medication list is consistent with the planed list. Med rec should be done on admission, change in level of care during an admission and on discharge.
- Every hospital stay will have one admission and one discharge med rec but may have many transfer med recs
- Every modern EMR has a med rec process as does McKesson Paragon
- Med rec does not have to be completed by one provider or all at the same time. Partially completed med rec can be saved as a Draft. This allows admitting and consulting physicians to verify the med rec prior to discharge or transfer.
Admission med rec
- This should be done BEFORE any other orders are placed
- From the CPOE tab choose Medication Reconciliation and choose the green circle under "Admission"
- From this screen you will have the opportunity to Continue, Defer, Modify or DC the home medications
Continue a medication
- Choose "Cont" to continue the same medication at the same dose and the same frequency during the admission
Defer a medication
- Chosing Defer (Def) on admission med rec will hold the medication for the whole admission
- The drug will show up on the discharge med rec where it may be resumed
Discontinue a medication
- Choose Discontinue (DC) to discontinue a medication for the admission
- The patient will most likely not be going home on this med and it will be removed from the home med list
- You will be asked for a Reason for DC
Modifying a medication
- Choosing Modify (Mod) allows the user to order the medication for the hospitalization but at a modified dose or frequency
- In the example below the dose was changed from 2mg to 3mg every day. The original order is what will remain on the patient’s home med list until discharge
Adding a drug
- A new drug can be added to at the time of the med rec my choosing "Add order" from the bottom right corner
Completing the med rec
- Once all orders have a yellow highlighted option next to them the "complete" button in the bottom left will be lit
- Complete button is greyed out? Make sure all buttons are checked
- Completing the med rec will process the orders.
- Transfer med recs on completion will drop all discontinued orders, start all added orders and modify all modified orders
Saving a med rec as draft
- Any partially completed med rec can be saved as a draft by choosing "save as draft"
- This draft can be opened by any other physician at a later time and edited
What should I do if a drug on the list is in italics?
- An improperly entered drug will show up with a dosing frequency in italics. This can happen if the dose or frequency is not known at the time of entering the medication
- The drug can only be defered, modified or discontinued
- If the drug is to be continued then modify the drug to correct the frequency
Correcting a drug frequency by modifying it
- Notice that the frequency is blank
- If the desired frequency is not in the drop down then click the red X
- Tip: typing "every" and searching will allow most dosing frequencies to be available
- Once the frequency is corrected click save
Free text medication
- Medications entered as free text cannot be reconcilled
- They will appear with a "txt" next to the label
- Choose "mod" to fully qualify the drug
- A drug can be free texted if the nurse cannot find the matching drug in the formulary
Searching for the free texted drug
Modifying a free text drug will take the user to the search box
Choosing the correct free texted drug
- Select the correct drug from the list
- Click save when the correct drug is selected
Discharge med rec
From the CPOE tab choose Medication Reconciliation and choose the Green Circle under "Discharge"
- Each medication will need to be marked as Cont, Mod or DC
- This list will include home and inpatient medications.
- Home medications will have a green icon with a house next to it
- Drugs discontinued during the Admission Med Rec will have icon of a red circle with DC next to the medication
Resuming a home med at discharge
- Home meds continued on admission may have a double listing as shown below
- To resume the home version click "DC"
- This will DC the inpatient entry of the drug and allow you to Cont the Home medication.
- Using this method will avoid having to answer the question "Is this an EXACT continuation of the Home Medication?"
Continuing an new dose of an admission modified drug
- When a home medication was modified on admission it will be entered on another line with a link to the admission drug
- To continue the inpatient dose and frequency of the drug at home click on "Cont"
- User will be shown the below popup asking for further clarification
- "Is this an EXACT continuation of the Home Medication?"
- Check off "Yes" or "No" and Save.
- If the new drug dose is to be continued on discharge then check the "No" radio button
- Click save when done
The list will now appear as follows
- A home med that is linked to an admission med cannot be discontinued until the inpatient med is first discontinued
- See the example below
- User will have to provide a reason for discontinuation of the drug
- Medications discontinued on admission will be already marked DC in the discharge med rec
- Unchecking the DC will allow to resume the home med
Notes on discharge med rec
- In order for the patient to go home with the patient discharge instructions without check boxes next to the medications the discharge Med Rec must be done electronically
- If a medication is added AFTER the discharge Med Rec is completed then the discharge med rec will print witl blank boxes or will have to be completed again