Process Description:
Medication Reconciliation is the process of making a good faith attempt to obtain a patients prior to admission medication history, which is eventually reconciled against a patients admitting medication list. Reconciliation involves identifying and clarifying intentional and unintentional discrepancies.
An accurate and reliable medication history taken on admission enables the continuation of appropriate therapy and ensures the patients care is seamless when transferring from home to hospital or from one healthcare facility to another.
Who Must Use this Process?
Pharmacists conducting medication histories, Pharmacy Technicians
Process Notes:
A patients medication history should be completed as soon as a patient is identified under the prioritization criteria
Patients will be interviewed by the Pharmacy technician in the order generated by the prioritization criteria. Other sources may be contacted to verify information.
The Pharmacy technician will make an accurate entry into Epic of the patients current medication regimen as communicated by the patient, family member ,care giver or SNF etc
The Pharmacist reviews the entry in EPIC for accuracy and to identify any discrepancies
Discrepancies should be discussed with the physician/ floor pharmacist as appropriate
Process Requirements:
CICARE training
Medication reconciliation technician training & evaluation
Epic training
Introduction to the ED set up (zones, work flow, multidisciplinary interaction, ED resources)
Process and Detailed Steps
Definitions
A. Track Board – a screen view of the electronic medical record (EMR) where progress of
Emergency Department patients is viewed and updated. Includes patient demographics, chief compliant, emergency severity index score, PTA med list status, etc.
B. ESI (Emergency Severity Index) – a triage system of screening and classifying patients to determine acuity and resource needs. ESI numbers range from 1‐5; the lower the number the more acute the patient.
C. Care Everywhere – a screen view of the patients’ profile in the EMR which contains the
patients’ specific records held with Sutter Health affiliates. Only available and accessible when a patient has agreed to release the information.
D. Rx Dispenses – a screen view of the patients’ profile in the EMR of the pharmacy dispense history available from the Surescripts system. Provides information on dates of dispensing, medication name, strength, dosage form, quantity dispensed and dispensing pharmacy.
E. Rx Snapshot – a screen view in the patients’ profile of the patients’ treatment team, current and past medical problems, vitals, laboratory results and medications ordered.
Completing the Daily Tasks List
1. Pharmacy technicians should complete items on the daily task list relevant to their shift (Appendix A).
Pharmacy technician obtains a list of prioritized patients from the ED Track board (Appendix B pages 2‐
8)
1. Log onto EPIC and click on the ED Track board Icon.
2. Prioritize the patient list in order of priority, as follows:
a. All patients in the Ready for Admit Screen b. Patients from the PTA Meds Review screen:
a. ESI 1 & 2
b. ESI 3 with the following (in order of priority):
Age > 65
Multiple Meds >4 Co‐morbidities c. CDU requests d. ESI 4 & 5
e. Patient’s in the waiting area of the ED yet to be prioritized and allocated ESI numbers.
Permission should be obtained from the patient prior to interview as this is an open area.
3. On occasion the hospital census may be full, and patients may “board” in ED extension. At the discretion of the pharmacist, technicians may go to this area to complete medication histories.
Pharmacy technician prepares the Admit Med Rec report and interviews the patient (Appendix B pages 8‐14)
1. Pharmacy technician prints Admit Med Rec report for the first 3 prioritized patients 2. Pharmacy technician reviews:
a. Chief complaint b. Past medical history
c. Previous dispense history (Rx dispenses), if available d. Care everywhere medication list, if available
e. Reconcile outside medications list, if available
f. ED notes in some cases to obtain pertinent medication information.
3. Pharmacy technician checks ED notes to ensure patient is at their bed before proceeding to interview them
4. Enters patients’ room and uses CICARE to introduce themselves and explains the process to the patient.
5. Verifies the patient using two identifiers ( Name, date of birth) 6. Verifies the patients preferred pharmacy(s)
7. Using Admit Med Rec report, interviews the patient using mainly open questions and closed questions if needed (Appendix C can be used as a guide)
a. Can you tell me what medications you are currently taking? Do you have any of your medications or a medication list with you? Do you have anyone who helps you with your medication? Do you live at home or in a facility?
b. Do you know if that is a tablet/ capsule/ liquid etc? Do you know what formulation that is?
c. Do you know what strength you take? How many do you take and how many times a day?
Clarify the time of day if necessary. When did you take the last dose of the medication?
d. If the patient is taking it differently to our records – Did your doctor advise you to adjust your dose or did you decide by yourself to take your medication differently?
e. Do you take any other medications that you can remember? Any over‐the‐counter medications, medicated creams/ ointments/ patches, use any inhalers, injections, eye drops/ ear drops, sprays, seasonal/ allergy medications?
f. Asks gender/ age appropriate questions – are you using any oral contraceptive medication? Do you use any hormone replacement therapy? Are you using any testosterone preparations?
g. Do you use any dietary/ vitamin supplements, herbal medications or supplements?
8. Technicians should ensure to return and interview patients who are with other staff members, or when they are interrupted during patient interviews, and obtain the remainder of the medication history.
9. Technicians should endeavor to return as soon as possible to start/ complete the interview.
10. For the period of time the patient remains in the ED, the Pharmacy technician must make as many good faith attempts as possible to interview the patient to obtain a complete history.
11. If the patient refuses to be interviewed or the Pharmacy technician is unable to obtain a medication history e.g. patient is unconscious, has altered mental status, does not recall their medications, the Pharmacy technician must contact other sources (see below) and make a good faith attempt to obtain a medication history during the time period while the patient remains in the ED.
12. Interviews should be concluded in the usual CICARE fashion.
Pharmacy technician assesses information given by patient & verifies medication history, if necessary
1. Pharmacy technician may contact other sources to verify all/ some of the information given by the patient
Examples of sources include:
a. Caregiver/ Family b. Pharmacy
c. Primary Care Provider d. Nursing Home/ Facility e. Clinics
f.
2. The Pharmacy technician should use their discretion to decide whether it is pertinent to obtain certain information e.g. we would not call a pharmacy to obtain the brand of multivitamin the patient is taking.
3. A maximum of 60 minutes should be spent actively working on obtaining a medication history for a patient and using all available sources.
4. The Pharmacy technician should refer any discrepancy or issue which they judge to be outside their scope of practice to the pharmacist on duty.
Pharmacy Technician annotates the Admit Med Rec report
1. Pharmacy technician uses the legends system to annotate the Admit Med Rec report (Appendix D).
2. Completes the audit label for each Admit Med Rec report (instructions Appendix E). The following criteria must be completed:
a. Tech initials b. Date
c. Time started d. Time finished e. Total time
f. Interview time (minutes)
g. Additional sources time (minutes) h. Number of discrepancies
i. Epic input time (minutes) j. Number of attempts
Pharmacy Technician updates PTA medication list on EPIC immediately after interviewing each patient (Appendix B pages 15‐17)
1. Pharmacy technician updates the medication list in ED navigator>PTA med document list 2. Each medication should be updated with:
a. Medication name, strength, dosage form b. Directions of administration
c. Taking/ not taking d. Last dose taken
3. Entries should be deleted if they are erroneous and re‐entered.
4. Medications absent from the list should be entered with the criteria listed in 2.
5. If technicians were unable to obtain some information regarding the medication(s) e.g. strength they should use the generic Epic entry e.g. Vitamin C PO
6. Yellow notes may be added to highlight discrepancies associated with a medication. A yellow note should only highlight discrepancies between what was prescribed and what the patient is taking.
a. In the interview, if a discrepancy is found the following questions should be asked:
b. Did the MD change this dose/tell you to stop taking or was this by patient choice?
c. Why was this change made?
d. How long ago was this change made?
e. To the best of our ability, the yellow note should then say, for example, “Pt was prescribed 2 tabs daily but patient elected to take 1 tab daily starting two weeks ago because he was dizzy”.
f. Use of yellow notes should be minimized and only reserved for communicating key information.
7. Administration instructions/ notes, should be used if additional information is obtained during the interview that elaborates on how the patient was taking the medication at home (eg. takes for back pain as needed, applies to scalp), that information is to be included in the administration
instructions and not in a yellow note.
8. Rx dispenses and Reconcile outside medications, functions can be used to add medicines to the PTA med lists.
a. Technicians will click on the “reconcile outside medications” link.
b. For each medication listed, technicians should select “add” or “discard”.
c. Select “discard” if the medication is an exact match for a medication on the PTA Med list d. If “add” is selected:
a. Technician will need to enter the medication sig (dose, route, frequency) b. Erase information in the “instructions” field
c. Click “file & close”
d. Editing that list does not change the Sutter Health record e. Entries should contain as much information as possible.
Pharmacy technician marks as Pharmacist review pending (Appendix B pages 18‐19)
1. Under Med List Status Pharmacy Technician selects one of the following:
a. Pharmacist review pending if the medication list is complete. Pharmacy technician enters one of the following + phrases:
a. .ptr +phrase (Pharmacy Technician reviewed PTA med with ***) and notes the sources used. Time, date and user are automatically recorded by Epic.
b. .nil + phrase (Patient states no current regular medication). Time, date and user are automatically recorded by Epic.
c. Incomplete if the medication list requires some follow‐up actions. Pharmacy technician can enter .ptu + phrase (Pharmacy technician unable to assess due to ***) and the reason stated. Time, date and user are automatically recorded by Epic.
Pharmacy technician hands off annotated Admit Med Rec report
1. Each report should be forwarded to the pharmacist immediately after the Epic entry.
2. Pharmacy technician places the Admit Med Rec report in the in‐tray in the ED satellite for pharmacist review unless:
a. There are unresolved or unusual discrepancies which should be handed off to the pharmacist in person.
Pharmacist checks the annotated Admit Med Rec report against the PTA med document list
1. See Standard Process Description: ED Pharmacist and Medication History (Appendix F)
Appendix A
S:\Med Reconciliation\Daily Tasks.docx
Appendix B
S:\Med Reconciliation\Pharmacy Forum\Med Rec Workflow ED ‐ illustrated.docx
Appendix C
S:\Med Reconciliation\Tech Training\Scenarios & Data Collection Form\Med Rec Data Collection Form.docx
Appendix D
S:\Med Reconciliation\Medication Reconciliation Technician Key.docx
Appendix E
S:\Med Reconciliation\Definitions.docx
