# Presentation: 937039

## Medication Reconciliation	

- Veterans Affairs North Texas Health Care System
- March 2008

## Objectives

- Explain the purpose of medication reconciliation
- Identify what medications and/or products need to be included in medication reconciliation process
- Describe when medication reconciliation occurs in the inpatient and outpatient setting

## Joint Commission Patient Safety Goal #8

- National Patient Safety Goal 2008
**Accurately and completely reconcile medications across the continuum of care**
- http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/08_npsg_facts.htm

## Definitions

- Medication Reconciliation
- A process of identifying a patient’s current list of medications that involves the patient and/or family as appropriate
- Medications
- Prescription medications (VA** **_**and**_** **non-VA)
- OTC medications
- Herbals, neutraceuticals, supplements, vitamins

## Definitions

- Patient’s Home Medication List
- _All __current__ medications_ including VA, Non-VA, over-the-counter (OTC) products and herbal supplements
- “Referred” Provider
- A provider within or outside the VA system in which a patient is referred to

## Intent of This Safety Goal	

- Avoid medication errors
- Omissions, duplications, dosing errors, drug interactions
- Determine appropriate therapy
- Providers will decide and order medications that need to be continued, discontinued and/or require a dose change

## Ensure that a complete medications list is communicated to the next provider when the patient is transferred to:
Another setting, service, practitioner or level of care
Regardless if it is within the North Texas VA system or outside the organization

- Another setting, service, practitioner or level of care
- _Regardless_ if it is within the North Texas VA system or outside the organization

**Intent of This Safety Goal****	**

## Responsibility

- The ordering provider, physician assistance, nurse practitioner, nurse, case manager and pharmacist will work together to ensure the completion of this process

## Responsibility

- The ordering provider is responsible for ensuring the completion of this process
- Another caregiver (nurse, clinical pharmacist) may complete this process; however, their reconciliation must be communicated to the patient’s provider

## Inpatient

## Admission

- Patient’s “home medication list” must be documented in the admission (H&P) note
- MUST include: outpatient medications (VA and non-VA), vitamins, OTC and neutraceuticals
- Document _non-VA medications_, _OTC_ products and _herbal supplements_ in
- “Orders” tab  “Medication, Non-VA” section

## Change in Level of Care

- Applies to change in _level of care_, _provider_ or _setting_
- Compare (or reconcile) current medications with new medication plan
- Address errors (omissions, duplications, drug-drug interactions)
- Complete and Sign new med orders

## Documentation: Changes

- Once _new_ medication orders have been signed, document a statement certifying reconciliation of all active meds in patient care note or generate a “Medication Reconciliation Note” in CPRS

## Documentation

**A CPRS Medication Reconciliation Note may be produced by going to: **
**“****Notes” tab******** click “New Note”**
- Type *Medication reconciliation* as note title
- This note will _auto populate_ with new
-     medication list
- 	****MUST enter new medication orders prior to creating note****

## Template

## Documentation

- Patient Transfer Notes must include a complete listing of the patient’s active medications

## Documentation

- If unfamiliar with a medication found in patient’s medication orders two options
- Take no action
- Consult with original prescriber or a pharmacist
- If another caregiver (i.e. nurse, pharmacist) generates the reconciliation note
- This action must be communicated to the patient’s provider

## Discharge

- Provider will compare (reconcile) the patient’s inpatient medications with “home medication list”
- Order and sign discharge medications
- Nurse may print the “Inpatient Discharge Instructions” for the patient
- Will reflect current outpatient and Non-VA medications only

## Discharge

- If patient is referred to a provider _outside_ VA system:
- It is **VA staff’s** responsibility to communicate the medication list to the “referred” provider
- It is _NOT_ the patient’s responsibility

## Outpatient

## Initial and Follow-up Visits

- “Patient’s Home Medication List”
- Current outpatient and non-VA medications
- Prescription, OTC, vitamins, neutraceuticals
- Documented as the “meds” tab

## Initial and Follow-up Visits

- Plan is known for outpatient medication
- “Orders” tab
**Add** new medications
**Document** non-VA meds
- Under “Medication, Non-VA” section
**Discontinue** medication therapies if warranted
**Renew** all medications that may expire prior to next visit (remove any duplicate orders)
**Sign medication orders**

## Documentation: Changes

- “Notes” tab click “New Note”
- Type *Medication reconciliation* as note title
- The note will auto populate with medications
****MUST enter new orders prior to creating note****
- New orders will show as pending
_**EXCEPTION**_: Schedule 2 Controlled medications must be documented under the templates “Comments section”

## Documentation: Changes

_**PRINT**_ to dedicated medication reconciliation printer
- Instruct patient to _pick-up_ medication list from **MAS clerk**  (or designee) as _they leave the clinic_
- Instruct patient to bring list to ALL clinic visits regardless of provider
- If **multiple** clinic visits
- Generate note as described previously
- _Last clinic provider _will print the final medication list

## Documentation: No changes

- If **NO** new medications are ordered, changed or discontinued
- Add addendum to patient care note documenting the appropriateness of the current medication plan

## Documentation

- If unfamiliar with a medication found in patient’s medication orders two options
- Take no action
- Consult with original prescriber or a pharmacist
- If another caregiver (i.e. nurse, pharmacist) generates the reconciliation note
- Reconciliation must be communicated to the patient’s provider

**Notes:**
Last sentence...See slide 13.  

## Referred Provider

- If patient is referred to a provider outside VA system:
- It is **VA staff’s** responsibility to communicate the medication list to the “referred” provider
- It is _NOT_ the patient’s responsibility

**Notes:**
Last sentence:  See slide 15.

## Assessment Questions

- In the _inpatient_ setting, medication reconciliation occurs upon:
- Admission
- Change in level of care
- Change in setting
- Change in provider
- All of the above

*Very IMPORTANT that patient’s medications are reconciled to ensure patient safety throughout the continuum of care*

**Notes:**
Add question regarding completing orders before generating note.

## Assessment Questions

- In the outpatient setting, “medication reconciliation” notes are created when NO changes to medications are made
- True
- False

*The note is created ONLY if changes (starting, stopping or changing medications) occur*

## Assessment Questions

- “Discharge” instructions (inpatient) or “Medication Reconciliation” note (outpatient) MUST be printed and given to the patient
- True
- False

*Discharge instructions or medication reconciliation note ****MUST**** be printed and given to each patient in order for them to bring to follow-up visits with other providers*

## Assessment Questions

- Changes, discontinuation or new medication orders need to be placed prior to generating a medication reconciliation note
- True
- False

*The template for the “medication reconciliation note” will auto populate with all active or new orders.  If the note is generated prior to new orders being entered, the medication list will be *_**WRONG**_

## Summary

- This is a **MANDATORY** requirement per Joint Commission Patient Safety Goal #8
- For more information or questions
- See VANTHCS Memo P&T 21
- Contact:
**	****	****Joann C. Fenicchia**
**	****	**Adm Officer, Clinical Quality Mgmt
- 		Telephone Number: (214) 857-2129
- 		_[Joann.Fenicchia@va.gov](mailto:Joann.Fenicchia@va.gov)_
- Joint Commission Website** **
- http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/08_npsg_facts.htm