Hospital Policies and Documentation

B. Documentation and Reconciliation

You sit down to write your history and physical and remember that Mr. Gomez is taking herbal and dietary supplements. How do you document all of this?

Documenting in Medical Records

As with hospital policies, electronic medical records (EMR) will also vary across different hospital systems. Despite the variations in entry methods, there are key things to keep in mind when you enter information into patients' chart. Just like with any medication, you will want to document any herb or dietary supplement use on the medication list.

Medical Reconciliation

Medical reconciliation is a formal process of obtaining a complete and accurate list of patients' current medications and comparing the list to the discharge orders, transfer list, and those taken prior to hospitalization. The goal for medical reconciliation is to develop a process that provides an accurate list that can be used as patients move within the medical system.

The Joint Commission also has specific requirements for hospitals when it comes to medical reconciliation. In fact, medical reconciliation has now become an inherent and crucial process in how we deal with patients on a regular basis. This is a link to the Agency for Healthcare Research and Quality PDF. Please review this briefly, and then move onto the next section on how to systematically approach medical reconciliation. 

Click here to view the slide presentation on Medical Reconciliation (PowerPoint)