# Presentation: 850837

## Medication Reconciliation Call: Kick-off callVANTS:  1-800-767-1750  Access Code:  41408

**Moderator** - Marta Render, M.D. VA Inpatient Evaluation Center
- Maureen Layden, M.D., White River Junction VAMC
- Keith Trettin, RPh., National Center for Patient Safety
- Dody Tyler, RN, Office of Quality and Performance
- Rob Silverman, PharmD, Hines VAMC
- Ursala Helmut, PharmD, Portland VAMC
- Carl Hensley, PharmD, VISN 23
- Phyllis Ahlman, RN, VACO
- Questions ? Contact : _[Phyllis.Ahlman2@va.gov](mailto:Phyllis.Ahlman2@med.va.gov)_

## A Story.....

- A patient with an artificial valve on coumadin comes into the ED complaining of cough productive of yellow sputum. Low grade fever, WBC 13K, Chest film is negative.
- He is sent home on levoquin
- He returns to the ICU 14 days later, short of breath, with a hgb of 5.0, and lower GI bleed.

## Conference call is a collaboration 

- VA National Center for Patient Safety
- VA Office of Quality and Performance
- VA 10 N
- VA Pharmacy Benefits Management Group
- Housekeeping items
- Your phones will be silenced during the call, if you have mute please use it as well.
- You can write in your comments using live meeting and panel will address at the end of call.

## Agenda

- The evidence for medication reconciliation 				                Maureen Layden, M.D.
- Patient safety goal #8
- 		               Keith Trettin, RpH and Dody Tyler, R.N
- The Hines Experience		Rob Silverman, PharmD
- The Portland Experience       Ursala Helmut, PharmD
- Get ‘ er done 	                   Marta Render, M.D. 					            w/ Maureen Laydon,M.D.
- Questions /Open Panel

## Improving Quality and Safety in the VA

- VA has an established record of improving quality in preventive measures, chronic disease management, and access in  out-patient setting.
- VA has a national reputation as a leader in improving patient safety
- VA Patient Safety initiatives
- Patient safety reporting system
- Reduction of VAP, CRBSI, and Surgical Site Infections
- Correct identification in the OR
- Limited abbreviations in medical orders and records
- Med TEAMS
- Bar coding of medications

## Required : A change in the care model

- Move to patient centered work where the only acceptable goal is ZERO injuries to patients
- To achieve this
- Adopt approaches that systematically support practice change
- USE multiple interventions aimed at the problem
- Measure / report processes and outcomes
- Plan small tests of change (getting it right, then spreading the practice)
- Evaluate admissions related to medications as a sentinel event
- Leaders across disciplines will use these approaches, to build consensus, to measure practice adherence and to eliminate injury due to incorrect medications.

## Goals for the call

- Identify 2 or more new strategies for improving medication reconciliation
- Identify a team (s) to create small tests of change in your hospital to improve medication reconciliation in OPC and transition in inpatient care.
- Create a 3 day (what can you do by Friday this week), a 30 day, and a 90 day plan for improvement.

## Evidence for Medication Reconciliation

- Lessons from the private sector
- (and the VA)

***‘******to care for him who shall have borne the battle and for his widow, and his orphan.***
***Abraham Lincoln’***

**Maureen Layden, MD VAQS VISN1**

**Slide 1**

**March 2007**

## Scope of the Problem

- In August 2006, the _[Institute of Medicine](http://topics.nytimes.com/top/reference/timestopics/organizations/i/institute_of_medicine/index.html?inline=nyt-org)__ of the National Academies released a major study on medication errors in American hospitals that found adverse drug events (ADEs) harm more than 1.5 million people and kill several thousand a year, costing at least $3.5 billion annually. _(Committee on Identifying and Preventing Medication Errors, 2006)
- Variances between medications patients were taking prior to admission and what was written on their admission orders ranged 30-70% in several studies. (Gleason, et al 2004, Cornish & Knowles, 2005, Vira et al, 2006)
- Luther Midelfort-Mayo found 250 potential or actual medication errors for every 100 charts. (Rozich & Resar, 2001)
- Most common discrepancy is omission of home medication (left off the list), followed by commissions (inappropriate medications that shouldn’t be ordered due to the patient’s condition, wrong dose, route etc.). (USP Patient Safety CAPSLink, 2005)
- Estimated >50% of adverse medical events occur at interfaces of care. (Resar,2005, Kripalini et al, 2007)

**Maureen Layden, MD VAQS VISN1**

**Slide 2**

**March  2007**

## What about the VA?

- In 2004, of 493 VA patients over 65 yo with 5+ medications, only 5.3% had perfect agreement with what they were taking and what was listed in CPRS. (Kaboli, 2004)
- Recent survey at the outpatient clinic at WRJ  VA, revealed 40% patients bring a list of medications or medications “brown bag”,<40% patients leave with an updated list. (Layden, 2007)

**Maureen Layden, MD VAQS VISN1**

**Slide 3**

**March  2007**

## You are Not Alone in this Struggle

- Institute for Safe Medication Practices in a May 2006 study showed nurses, pharmacists, both outpatient and inpatient, 91% knew of National Patient Safety Goal (NPSG) #8.
- 89% of sample felt it added great value to patient safety.
- A Medication Reconciliation process was in place at 25% hospitals for 6 months, 18% for 1 year or more.

**Maureen Layden, MD VAQS VISN1**

**Slide 4**

**March  2007**

## Why Medication Reconciliation?

- Decreased ADEs; 43% at Cambridge Health Alliance after institution of Medication Reconciliation program. (Bartick & Baron, 2006)
- Decreased overall time spent; On average 20-40 minutes at each interface due to eliminated rework. (Rozich & Resar, 2001)
- Decreased costs; NW Memorial Chicago Medication Reconciliation cost $11 per patient, but ADEs cost $2000-6000 per patient, at 4% error rate, approx $80 per patient. Costs:
- Readmission, increased LOS.
- Extra office, urgent care, ER visits, patient calls. (Gleason, et al, 2004)
- May increase patient & staff satisfaction. (Cohen,2006)

**Maureen Layden, MD VAQS VISN1**

**Slide 5**

**March 2007**

## And More!

- It’s patient centered.
- The fundamental definition of our work.
- Avenue for education, shared decision, & transparency.
- A potential tool for measuring ADEs, “compliance”, & other problems with medication management. (Bookvar,2006)
- Encourages us to formalize communication streams with external & internal colleagues.
- And of course, it’s Joint Commission NPSG #8.

**Maureen Layden, MD VAQS VISN1**

**Slide 6**

**March 21, 2007**

## Keys to Success (from the Private Sector)

- Gather local data:
- Discrepancies/total medications. http://www.macoalition.org/Initiatives/RMMeasuresFAQ.shtml
- Throughput, flow, potential barriers (i.e. Do you have enough printers?)
- Identify and hold accountable who will perform the tasks of Medication Reconciliation and the time frames for completion. (Anderson,2006)
- Educate and galvanize your staff, organize teams, especially prescribers. (Alper, 2006)
- Provide monthly data reports, run PDSA cycles.
- Start small!

**Maureen Layden, MD VAQS VISN1**

**Slide 7**

**March 2007**

## Barriers to Success (PVT Sector) 

- Caution: One size does not fit all! (Rodehaver & Fearing, 2006)
- Failure to engage end users early. (Alper,2006)
- Implementing extra steps, think streamline! (Anderson, 2006)
- Focusing on Joint Commission and not the patient, healthcare team, process.
- Lack of ongoing education, support, and feedback mechanisms. (Alper, 2006)

**Maureen Layden, MD VAQS VISN1**

**Slide 8**

**March 2007**

## Medication Reconciliation

- Will fundamentally change how we practice medicine by systemizing the management of the medical treatment plan, placing checks and balances at every interface, and instituting an ongoing dialogue with the patient and his/her healthcare team.

**Maureen Layden, MD VAQS VISN1**

**Slide 9**

**March 2007**

## Maureen Layden, MD
Fellow, VA Quality Scholars Program
VAMC (11Q)
215 North Main Street
White River Junction, VT 05009-0001
Phone:802 295-9363 Ext.6032
Fax:802 291-6286
Email: Maureen.Layden@VA.gov 
Email: Maureen.Q.Layden@Dartmouth.edu

- Maureen Layden, MD
- Fellow, VA Quality Scholars Program
- VAMC (11Q)
- 215 North Main Street
- White River Junction, VT 05009-0001
- Phone:802 295-9363 Ext.6032
- Fax:802 291-6286
- Email: _[Maureen.Layden@VA.gov](mailto:Maureen.Layden@VA.gov)__ _
- Email: _[Maureen.Q.Layden@Dartmouth.edu](mailto:Maureen.Q.Layden@Dartmouth.edu)_

**Maureen Layden, MD VAQS VISN1**

**Slide 10**

**March 2007**

## Medication Reconciliation3/28/2007

**Keith W. Trettin R.Ph, MBA**
**VHA National Center for Patient Safety**
**Keith.Trettin@va.gov****	**
**734-930-5848**

## The Joint Commission 2007National Patient Safety Goals

**Improve the accuracy of patient identification.**
**Improve the effectiveness of communication among caregivers****.**
**Improve the safety of using medications. **
**(Retired) - Eliminate wrong site, wrong patient, and wrong procedure surgery.**
**(Retired) - Improve the safety of using infusion pumps.**
**(Retired) - Improve the effectiveness of clinical alarm systems.**
**Reduce the risk of healthcare-associated infections.**
**Accurately and completely reconcile medications across the continuum of care.**

**Reduce the risk of patient harm resulting from falls.**
**Reduce the risk of influenza and pneumococcal disease in institutionalized older adults.**
**Reduce the risk of surgical fires.**
**Encourage the active involvement of patients and their families in the patient’s own care as a patient safety strategy.**
**Prevent healthcare-associated pressure ulcers (decubitus ulcers).**
**The organization identifies safety risks inherent in its patient population.**
**15A: The organization identifies patients at risk for suicide.**
**15B: The organization identifies risks associated with long-term oxygen therapy, such as home fires****.**

## VA & Non-VA Percent (%) of Frequently Cited JCAHO NPSGsAll Accreditation Programs (Hospital, BHC, HC LTC)

| 
National Patient Safety Goals
 | VA NPSGs 
(n=112)
# Surveys:  151 |  | * Non- VA NPSGs
(n=4149)
# Surveys: 3538 |  |
| --- | --- | --- | --- | --- |
| NPSG 1:  Accuracy of Identification | 9 | 8% | 210 | 5% |
| NPSG 2:  Effectiveness of Communication | 28 | 25% | 1381 | 33% |
| NPSG 3:  Safety of Using Medication | 9 | 8% | 321 | 8% |
| NPSG 7:  Health Care Associated Infections | 15 | 13% | 322 | 8% |
| NPSG 8:  Reconcile medications | 28 | 25% | 991 | 24% |
| NPSG 9:  Harm Resulting from Falls | 9 | 8% | 431 | 10% |
| NPSG 10:  Influenza & Pneumococcal Vaccination | 0 | 0% | 3 | 0.1% |
| NPSG 13:  Patient Active Involvement | 1 | 1% | 68 | 2% |
| NPSG 14:  Pressure Ulcers | 1 | 1% | 3 | 0.1% |
| →  UP1:  Wrong Site/Wrong Person Surgery  ← | 12 | 11% | 419 | 10% |

## What’s New for 2007? 

**Goal 8 - Accurately and completely reconcile medications across the continuum of care.**
**	****8a There is a process for comparing the patient’s current medications with those ordered for the patient while under the care of the organization**
**	****8b (CHANGES IN CAPS): A complete list of the patient’s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner, or level of care within or outside the organization. ****THE COMPLETE LIST OF MEDICATIONS IS ALSO PROVIDED TO THE PATIENT ON DISCHARGE FROM FACILITY****.**

## Definition of Reconcile

- Reconcile - To compare and reach agreement
- To avoid errors of transcription, omission, duplication of therapy, drug-drug and drug-disease interactions etc. JC FAQ Pg 1

## Medication Reconciliation (8a & b)

- The medication reconciliation requirement may be perceived as “new” in 2007 but it isn’t.
- Was announced in July 2004.
- 2005 was for “developing a process”
- 2006 “implement the process” it was a requirement and was surveyed by JCAHO as such
- Availability of a current list of medications has been established under Medication Management standard M.M. 1.10
- New for 2007 is reconciled patient medication list  (aspect of 8b).

## 8a – Medication Reconciliation (2006)

- Organizations must implement a standardized method for creating an accurate list of medications at admission/entry and transfer. The list should include the full range of medications as defined in the accreditation manuals.
- Development of a medication reconciliation form, to be used as a template for gathering information about current medications, is one method that can be used to standardize care and prevent errors.

**Prescription medications**
**Sample medications**
**Vitamins**
**Nutraceuticals**
**Over-the-counter drugs**
**Vaccines**
**Diagnostic and contrast agents**
**Radioactive medications**
**Respiratory therapy-related medications**
**Parenteral nutrition**
**Blood derivatives**
**Intravenous solutions (plain or with additives)**
**Any product designated by the FDA as a drug**

## Medication Reconciliation (2007): 8b’s New Requirement for Print-out

- Reconciled/updated medication list to be provided to patients at Discharge “Exit”JC FAQ pg10
- Explicitly applies to “Hospital” and “Ambulatory Care” settings
- Applies to all inpatients
- Applies to outpatients with changes in medications
- Changes include new meds, discontinued meds, dosage or route changes, etc.

## FAQ

- Is a written policy on Medication Reconciliation required?
- -Nothing in NPSG#8 requires a written policy, but..

## FAQ

- Is documentation of the reconciliation required?
- -The only required documentation is the list itself. Each individual organization is to determine how it will monitor compliance. JC FAQ pg 3

## FAQ

- Does this standard apply to Primary Care only?
- -No, It applies to all clinics not just primary care. Mental Health clinics, specialty medical surgical clinics, dental, podiatry: all have to meet this standard.

## FAQ

- What about immunization clinics or other areas of “minimal medication use” areas?
- -A list of patient’s current medications and a history of allergies and past sensitivities must be obtained. MM 1.10
- -”Reconciliation”, in this context simply means checking the patient info. to make an informed decision about the use of minimal medications. JC FAQ pg 2,8,17

## FAQ

- Who is supposed to do the reconciliation?
- -Neither the goal nor its requirements or implementation expectations specify who is to do the reconciliation. The MC policy will determine.

## FAQ

- Must reconciliation be done at every clinic visit?
- -During an initial visit a complete list of the patient’s medication must be determined. Thereafter, it is simply a process of looking at the list when new meds are ordered, updating the list to reflect changes and giving the list to the patient. How the list is updated in based on the MC’s policy.
- -If there are other providers of care who are not part of the clinic but who are currently participating in the care of the patient, the list should be communicated to them whenever updated. JC FAQ Pg2

## What You Should be able to explain about Medication Reconciliation:

- What is your MC policy for Medication Reconciliation. How is compliance evaluated?
- How do medical care providers outside and inside the VA receive the medication information?
- How is the patient solicited to participate in their own care including Med Rec?

## Joint Commission Findings from VA surveys 2007 TD 3-22-07 

- Doris Tyler
- Office Quality & Performance Accreditation Program

## 2007 Medication Reconciliation Details from VA JCAHO Survey RFIs

| National Patient Safety Goals | Hospital
(85) # NPSG=25 | BHC (9)
# NPSG=1 | HC (27)
# NPSG=8 | LTC (16)
# NPSG=3 | LAB (1)
# NPSG=1 | Total (138) 
NPSG =38 |
| --- | --- | --- | --- | --- | --- | --- |
| NPSG 8:  Reconcile medications | 4 | 1 | 1 | 0 | 0 | 6 |
| 8a.  Obtain/document patients current medications | 2 | 1 | 
1
 | 0 | 0 | 4 |
| 8b.  Communicate current medications to next provider, etc. | 2 | 0 | 0 | 0 | 0 | 2 |

- 2007TD – 27.5% of all RFIs in Hospital surveys are related to Patient Safety.

**(as of 3/22/07)**

## Medication Reconciliation

- Rob Silverman, PharmD
- Hines VA Hospital
- E-mail:  robert.silverman2@va.gov

## Slide 36

| Goal 8 | Accurately and completely reconcile medications across the continuum of care. |
| --- | --- |
| 8A | There is a process for comparing the patient’s current medications with those ordered for the patient while under the care of the organization. |
| 8B | A complete list of the patient’s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization. The complete list of medications is also provided to the patient on discharge from the facility. |

## ...across the continuum of care 

- The need: a report that assists in the comparison of medications from one domain of care to another
- Focus on: discharge from inpatient stay – are all inpatient medications accounted for on the outpatient profile
- The result: a Health Summary called Medication Reconciliation Profile

## Slide 38

## Slide 39

## Medication Reconciliation Profile

- Primary intent
- Compare inpatient, outpatient and non-VA medications in a single list
- Generate ‘couplets’ of related medications

## ... [list of medications provided to the patients]

- The need: a single list that can be printed easily and contains information in a patient-friendly format
- Focus on: using methods familiar to staff
- The result
- Option 1 – Health Summary “Med Chart”
- Option 2 – TIU Template used as the list

## Slide 42

## Slide 43

## Slide 44

## Slide 45

## Slide 46

## Local and National

- Each of the previous slides incorporates some locally developed programming
- On the national front, a New Service Request (NSR) was entered to request software that addresses these issues
- _[http://vista.med.va.gov/pas/ViewTrackingRecord.asp?RequestID=20070108](http://vista.med.va.gov/pas/ViewTrackingRecord.asp?RequestID=20070108)_

## New Service Request

- Two primary needs
- Medication List
- Tool for the reconciliation process
- Current status = “Analysis Ongoing” by Planning and Analysis Service

## Medication Reconciliation

- The Portland VA Medical Center Journey
- Presented by:
- Ursula Helmut, Pharm.D
- PVAMC Pharmacy Services
- E-mail:  ursula.helmut@va.gov

## Acknowledgements

- 	Blake Lesselroth MD MBI, Robert Felder DDS MPH, James Maloney, Tamara Olcott MS, Aida Solomon RN, Ursula Helmut, PharmD, Raphael Rook MHA, Anne Lubischer PharmD, Thomas A. Anderson MD, Judy McConnachie MPA, David Douglas MD
- 	Patient Safety Committee, Portland Center for Evaluation of Clinical Services, Technology and Information Management Services, Department of Hospital and Specialty Medicine, Pharmacy Service
**Portland VA Medical Center**
**Portland, Oregon**

## The Process

- Assess and identify resources and key stakeholders
- Assemble the Medication Reconciliation Working Group
- Identify a manageable set of objectives
- Collect baseline data, work flow modeling & FMEA
- Development of internal strategies and IT tools
- Training & Implementation
- Reassess and make improvements on the work that has been done.

## Medication Reconciliation Working Group

- Medication Reconciliation Working Group

## Identification of Goals

- Joint Commission’s National Patient Safety Goals for 2007
- Implement a process for obtaining and documenting a complete list of the patient’s current medications
- Communicate an accurate medication list to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care
- Provide this medication list  to the patient at the time of discharge from the facility

## A Modular Approach 

- Work Flow Modeling

## Electronic Unified Action Profile (eUAP)

- A modification of the CPRS graphical user interface
- Aggregates inpatient and outpatient medication couplets together on the CPRS Orders tab
- Provides actionable menus and easy to review lists within CPRS to support Provider’s reconciliation decisions

## Slide 57

## Slide 58

## Patient Education Packet (PEP)

- A VistA menu option used by pharmacists
- Documents new orders created by the eUAP
- Generates a clinical summary on the Reports tab
- Creates a handout for patient education and reference purposes

## Slide 60

## Slide 61

## The Journey Continues

-  Improve on the work we have done
-  Spread to other transition points in the   continuum of care

## Slide 63

## Get ‘er done

- Tomorrow: Select your _willing _champion team
- 1 Provider
- 1 Nurse
- 1 Front desk person
- 1 Patient to be seen Friday by this team
- Friday before clinic:
- Print out a list of patient’s medications
- 	from the Templates Shared Templates  Patient Data Objects Medication List

## It can be done!

- Patient checks in:
- Front desk person gives the list to patient
- Nurse highlights medication discrepancies
- Provider and patient then come up with final list
- Patient is discharged:
- Give the corrected medication list to the patient

## At 4 weeks, expand!

- PDSA small tests of change i.e.
- Front desk person gives the list to patient
- Send the list to the patient (s) with appointment information prior to visit
- Nurse highlights medication discrepancies
- Provider and patient come up with a final list
- Patient is discharged:
- Give the corrected list to the patient
- Nurse keeps record of number of discrepancies/total medications
- Schedule a meeting for the entire department to present initial findings after 4-8 weeks of improvement

## At 12 weeks, spread!

- Continue PDSA small tests of changes
- Set goal for all patients of the champion team to have medications reconciled each clinic by 12th week
- Start team 2, 3, etc
- Set goal for all patients in this clinic to have medications reconciled at every visit
- Provide monthly updates include challenges +successes
- Develop a near miss report
- Plan a 6 month celebration!!!
- Does it stop there?

## This is Continual Improvement!

- Continue PDSA small tests of changes
- Use the great new software Hines has developed
- Consider being part of a collaborative VA, non-VA
- Spread to other settings
- Set goal for all patients of the champion team to have medications reconciled _and_ ADEs recorded by 9 months
- Spread ADE recording to the remaining teams
- Set goal for all patients in this clinic to have medications reconciled at every visit & ADEs recorded by 12 months
- Continue to provide monthly updates & near miss reports
- Start ADE control charts
- Plan a 12 month celebration!!!
- Does it stop there?

## |PATIENT NAME|

- |PATIENT ADDRESS|
- |PATIENT DATE OF BIRTH|
- |PATIENT SSN|
- Name/Phone Number/Address of your Non-VA doctors:
- _________________________________________________
- _________________________________________________
- |CURRENT ADMISSION DATE/TIME|
- Dear |PATIENT NAME(MR. LASTNAME)|,
- Good Morning! Please look over the following medication lists and check to
- make sure we have listed the medications you are taking at home. These are your
- "ACTIVE" Medications.
- Please write your corrections down next to the medication.
- Note some medications are "DISCONTINUED" which means you are no longer taking
- this medication.
- Note some medications are "EXPIRED" which means you may need a refill.
- If you'd like, you can jot some questions, issues down on this form for
- us to go over today.
- Thanks you for your time and effort in filling this out,
- See you Soon,
- Maureen Layden. MD
- These Medications are correct YES____  NO____ (Corrections below)
- |RX: DETAILED ACTIVE W/EXPIRED MEDS|
- These Medications are correct: YES____ NO____ (Corrections below)
- |NON VA MEDS|
- Allergies/Adverse Reactions:
- |ALLERGIES/ADR|
- Questions, Issues:
- _____________________________________________________________________________
- _____________________________________________________________________________
- _____________________________________________________________________________

## Maureen Layden. MD 

- STANDARD TITLE: PRIMARY CARE ADMINISTRATIVE NOTE
- DATE OF NOTE: MAR 27, 2007@11:05     ENTRY DATE: MAR 27, 2007@11:05:15
-       AUTHOR: LAYDEN,MAUREEN       EXP COSIGNER:
-      URGENCY:                            STATUS: UNSIGNED
-      SUBJECT: Medication Reconciliation
- Veteran, Joe
- 1 Main St
- Any Town, NEW HAMPSHIRE
- Jan 1,1965
- 000-00-0000
- Name/Phone Number/Address of your Non-VA doctors:
- _________________________________________________
- _________________________________________________
- Dear Mr. Veteran,
- Good Morning! Please look over the following medication lists and check to
- make sure we have listed the medications you are taking at home. These are
- your "ACTIVE" Medications.
- Please write your corrections down next to the medication.
- Note some medications are "DISCONTINUED" which means you are no longer taking
- this medication.
- Note some medications are "EXPIRED" which means you may need a refill.
- If you'd like, you can jot some questions, issues down on this form for
- us to go over today.
- Thanks you for your time and effort in filling this out,
- See you Soon,
- Maureen Layden. MD

## Questions, Issues:

- Active and Recently Expired Outpatient Medications (excluding Supplies):
-                                                             Issue Date
-                                                Status       Last Fill
-      Active Outpatient Medications             Refills      Expiration
- =========================================================================
- 1)   ATENOLOL 25MG TAB  Qty: 90 for 90 days    ACTIVE       Issu:08-14-06
-        Sig: TAKE ONE TABLET BY MOUTH EVERY     Refills: 1   Last:03-02-07
-        DAY FOR BLOOD PRESSURE/HEART                         Expr:08-15-07
- 2)   CARBOXYMETHYLCELLULOSE NA 1% OPH SOLN     ACTIVE       Issu:11-02-06
-        Qty: 90 for 90 days  Sig: INSTILL 1     Refills: 3   Last:11-03-06
-        DROP IN BOTH EYES AT BEDTIME AS NEEDED               Expr:11-03-07
-        FOR DRY EYES
- 3)   DOXYCYCLINE HYCLATE 100MG CAP  Qty: 90    ACTIVE       Issu:11-02-06
-        for 90 days  Sig: TAKE ONE CAPSULE BY   Refills: 3   Last:11-03-06
-        MOUTH EVERY DAY FOR INFECTION USE FOR                Expr:11-03-07
-        CHRONIC OCULAR ROSACEA
- Issue Date
-                                                Status       Last Fill
-      Inactive Outpatient Medications           Refills      Expiration
- =========================================================================
- 1)   ATENOLOL 25MG TAB  Qty: 90 for 90 days    DISCONTINUED Issu:02-22-06
-        Sig: TAKE ONE TABLET BY MOUTH EVERY     Refills: 3   Last:05-11-06
-        DAY FOR BLOOD PRESSURE/HEART                         Expr:02-23-07
- 2)   CICLOPIROX 8% TOP SOLN  Qty: 6.6 for 60   EXPIRED      Issu:12-02-05
-        days  Sig: APPLY APPLICATION TOPICALLY  Refills: 1   Last:12-02-05
-        EVERY DAY FOR FUNGAL INFECTION OF THE                Expr:12-03-06
-        NAIL(S) ---
- 3)   FINASTERIDE 5MG TAB  Qty: 90 for 90 days  DISCONTINUED Issu:12-09-05
-        Sig: TAKE ONE TABLET BY MOUTH EVERY     Refills: 2   Last:05-24-06
-        DAY FOR PROSTATE                                     Expr:12-10-06
- 4)   GLYBURIDE 5MG TAB  Qty: 180 for 90 days   DISCONTINUED Issu:02-23-06
-        Sig: TAKE ONE TABLET BY MOUTH TWICE A   Refills: 3   Last:02-23-06
-        DAY FOR DIABETES -- NOTE: DIRECTIONS                 Expr:02-24-07
- 7 Total Medications
- These Medications are correct: YES____ NO____ (Corrections below)
- NON-VA MEDS - NONE FOUND
- Allergies/Adverse Reactions:
- IONIC CONTRAST MEDIA
- _____________________________________________________________________________
- _____________________________________________________________________________
- ___________________________________________________________________________

## Slide 72