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What is an Admission Medication Reconciliation?
The admission medication reconciliation (Med Rec) is the process used to document all of the patient's home medications including the last time they were taken, remove records of medications that are no longer part of the home med list, or change records of medications that have changed dose or frequency since the last time they were documented. After this, the medication reconciliation is completed by writing orders for any of these medications that are necessary while the patient is under our care. Depending on the complexity of the patient, a Med Rec usually takes about 5 to 10 minutes.
Which Patients need a Med Rec?
Most patients going to CDU need a Med Rec at the time they are admitted to the CDU. This is most important for patients with chronic medical conditions who are on prescribed medications. This includes patients who are "Obs in the Zone" for Mental Health and Sober Re-evals, as these patients are frequently on critical medications such as anti-epileptic medications. If a Med Rec is truly not possible (patient is obtunded and no outside records available) then this must be documented as a problem on their problem list and signed out to the next provider. A Med Rec may be deffered until morning or when pharmacy arrives the next day ONLY if admitting provider can ensure the following:
Any Critical home medications (e.g. Anti Epileptics, Anti Arrhythmics, etc) are still ordered and given overnight.
"Needs Medication Reconcilliation" is listed as a specific problem in the patients assesment and plan for the morning provider to complete.
But Doing a Med Rec Sucks!
You're right. It sucks. It's time consuming. It's not part of what we frequently do as ED Physicians. It is absolutely not optional.
All providers working in our ED are expected to know how to do a Med Rec, and to do one when a patient is admitted to CDU outside of pharmacy coverage hours.
Medication Reconciliation by Pharmacy
Thankfully we have a pharmacist available from 11:00 to 21:00 each day to do the Med Rec for us. We are hoping to expand the hours of this coverage, but pharmacy, like everyone else these days, is looking for ways to cut, not add to costs.
Outside of the hours of 11:00 - 21:00, it is the responsibility of the provider writing the admission orders to do a Med Rec.
How to do an admission Med Rec
Chart Review before doing a Med Rec - look at the outpatient medication lists in the Care Everywhere or eSummit chart (if they have a PCP at SCL). If the patient has been discharged from an inpatient hospitalization recently, look at the medication list from the last DC summary. For shorter lists, I usually just jot down the med list on a paper, for longer or more complex medication lists, I will print the page from the EMR. If a patient has no records in Care Everywehere or eSummit, try CORHIO. As a last resort you can call the pharmacy where they fill their medications.
Go to the Patient's bedside and review the medications - with the patient or caregiver, confirm the active medications, the dose, the route and the frequency that they report taking. If possible note when the last dose was taken.
3. Click the "Dispo" tab in eSummit
4 . To open the Med Rec tool in Epic. Click the "Transfer Rec" button on the Dispo Tab
5. Review the home medications listed. If the medication is accurate, mark "Taking?" box (a), and note the last dose. If the medication is correct, but the dosage or timing has changed, click "Taking Differently" (b) and adjust accordingly. If you want to leave a note about the medication for the doc at time of discharge (e.g. patient requesting refill), click the small paper icon (c).
6. If a patient is no longer taking a medication, then click the red "X" (d) on the right hand side of the medication, and then "Accept" in the Pop-Up. A reason for discontinuing the medication is not necessary.
7. Add any medications not yet listed. The best way to do this is to free text the name of the medication into the text box named "New Prior to Admission Med"
8. You can also add medications by pulling them from their outpatient charts and records by clicking on the "Go reconcile" button next to the orange banner stating the Medications from Outside sources need attention
But the screen that pops up when you do this is often very chaotic. If you want to learn more about how to use this feature, I'm happy to show you, but it's often more work than entering medications manually
9. When you are satisfied that the medication list is accurate, please designate that you have completed the review of prior medications by selecting the drop-down menu next to "Med List Status" (A), selecting "Provider Complete" from the list (B), and then "Mark as Reviewed" (C).
10. Congrats. The hard part is done. Now click the "Next" button at the bottom right of the screen.
11. The last task in the Med Rec is to choose to designate which of the patients home medications will be ordered while they are in the CDU. "Order", changed "Replace" or held "Don't Order"
12. When all home medications have been either ordered, held or replaced, the Med Rec is done. You can sign your work at this point - by clicking "Sign and Accept" on the lower right corner or you can click the arrow pointing right to continue to the Order Sets page, where you will enter in new orders for care in CDU Order Set and then sign the work all together.
Congratulations! You're done!
Congratulations! You're done!
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