Medical Reconciliation and Documentation

1
Medical Reconciliationand Documentation
2
Definition

• Medication Reconciliation is a process of
  obtaining a list of the patients 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 patients current pharmacy
• The patients physicians office or clinic
• The patients 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 patients 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