Hospital Policies and Documentation

B. Documentation and Reconciliation

How to systematically approach medical reconciliation:

STEP 1: Obtain a medication history

Obtain the most accurate list possible of the patient's current medications upon admission. This includes prescription and over-the-counter medications, herbals and dietary supplements listing the dose, route, frequency, indication, and time of last dose.

Besides the patient and family, other sources of information may include visual inspection of the drug or supplement bottles brought into the facility by the patient or family, previous medical records, as well as the patient's pharmacy and physician office.

STEP 2: Prescribe medications

When your list is complete, review and act upon each medication on the list while prescribing the patient's admission medications.

STEP 3: Reconcile and resolve discrepancies

STEP 4: Reconcile again upon transfer and discharge

Each time a patient moves from one setting to another, review previous medication orders alongside new orders and plans for care, and resolve any discrepancies.

When the patient is discharged, the reconciled list of admission medications must be compared against the physician's discharge orders along with the most recent medication administration record. Any differences must be fully reconciled before discharge.

STEP 5: Share the list

Communicate a complete list of the patient's medications to the next provider of service when transferring a patient to another setting, service, practitioner, or level of care within or outside the organization. This includes sending a list of medications prescribed upon discharge from the hospital to the patient's primary care physician, as well as encouraging patients to share the list with their pharmacy.

Summary

Medical reconciliation needs to happen three times--once, during admission to reconcile what he was taking; again, when you write his medical orders; and then again on discharge. When documenting about HDS usage by patients, use the same technique and detail as with medications.

Now it's your turn! Go to the next page to fill out a medical reconcilation list for Mr. Gomez.