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st American Systems and Services LLC

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Medication Reconciliation and Standards Overview

August 31, 2011

Prepared by 1st American Systems and Services LLC

for 

National Institute of Standards and Technology
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1st American Systems and Services LLC

469 Township Road 1535

Proctorville, OH 45669 

www.1asas.com

Authors

Frank McKinney

fm@frankmckinney.com

Laura Topor 

ltopormn@msn.com
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 1

st American Systems and Services LLC | NIST NCPDP Analysis

NIST NCPDP Analysis – Medication Reconciliation and Standards Overview

Final, August 31, 2011

Contents

A. Introduction.........................................................................................................................................4

B. Working Definitions of Medication Reconciliation................................................................................5

C. Medication Reconciliation Process Background....................................................................................7

D. Overview of Medication Reconciliation Challenges at Transfer of Care.................................................8

E. Information Exchange Standards and Medication Reconciliation........................................................10

Medication History (NCPDP SCRIPT RXHREQ, RXHRES)...........................................................................10

Continuity of Care Record (ASTM CCR)...................................................................................................10

Continuity of Care Document (HL7 CCD) ................................................................................................10

Prescription Fill Status (NCPDP SCRIPT RXFILL) .......................................................................................11

F. High-level Comparison of Medication Concepts in SCRIPT, HL7 CCD, and CCR ....................................12

G. Summary of Support, Challenges and Opportunities ..........................................................................16

Coded Terminology................................................................................................................................16

Linking Ordered and Dispensed Medications .........................................................................................17

Appendix A –Joint Commission’s National Patient Safety Goal for Medication Reconciliation (prior version)

..................................................................................................................................................................19

Appendix B: Institute for Healthcare Improvement – Medication Reconciliation Process...........................22
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A. Introduction

The goal of this document is to provide an overview of the medication reconciliation process and a high-level 

review of three electronic information exchange standards that support it—with a focus on potential 

challenges arising from integrating those standards in a single workflow.

It provides a brief background on the process itself, industry stakeholders and definitions, and problems the 

process is intended to address. In addition, it identifies the pertinent electronic information exchange 

standards, including key segments, modules, and data elements and their use in the process. It also considers 

interaction checking—drug/drug, drug/allergy, etc.—as a component of medication reconciliation and 

discusses electronic information exchange in the context of that process.

Document sections:

Working Definitions of Medication Reconciliation. Definitions of “medication reconciliation” from 

industry stakeholders including the Institute for Healthcare Improvement and the Joint Commission.

Medication Reconciliation Process Background. High-level review of typical medication 

reconciliation events and processes, including review of current and past medications, interaction 

and allergy checking, and prescribing of new medications.

Overview of Medication Reconciliation Challenges at Transfer of Care. Overview of studies on 

adverse drug events during transfers of care. Examples of medications and contributing factors to 

adverse drug events.

Information Exchange Standards and Medication Reconciliation. Overview of NCPDP SCRIPT and 

other standard transactions/messages that support medication reconciliation. Analysis of key 

segments, modules, and data elements and their use in the process. Description of information flows 

between data sources, the prescriber system, and other participants . Consideration of interaction 

checking within the context of medication reconciliation and related information exchange.

High-level Comparison of Medication Concepts in SCRIPT, HL7 CCD, and CCR. Identification of 

common medication concepts between the NCPDP SCRIPT 10.6 Medication segments, Continuity of 

Care Document medications module (as defined in the C32 CCD definition), and the ASTM Continuity 

of Care Record (CCR)—including high-level comparison of data elements and terminology.

Appendix: Prior version of Joint Commission’s National Patient Safety Goal for Medication 

Reconciliation.

Appendix: Institute for Healthcare Improvement – Medication Reconciliation Process.
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B. Working Definitions of Medication Reconciliation

Medication reconciliation is intended to be a systematic process designed to enhance patient safety by 

validating at every point of care a patient’s current medication regimen. As patients are seen by a multitude 

of providers, in a variety of settings, reviewing and revising their medications (prescription and over-thecounter) is an important step in improving quality and safety. The industry has struggled to develop and 

implement the most efficient and effective process to accomplish this task. The transition from paper to 

electronic medical records has also been a factor in determining how to consistently perform medication 

reconciliation.

There is no doubt that improving the ability of the healthcare industry to exchange medication information 

will lead to reduced errors and better outcomes. The challenges are many, but the existence of a standard to 

exchange medication data is an important first step. Many of the processes used today to perform 

medication reconciliation are manual. Achieving interoperability by using RxNorm and the NCPDP standards 

will allow for some of those processes to be completed systematically, allowing the clinician more time to 

focus on patient care and not “paperwork”.

(All taken from http://www.ihi.org/IHI/Topics/PatientSafety/MedicationSystems/Tools/Medication+Reconciliation+Review.htm

2/22/11) 

According to the Institute for Healthcare Improvement (IHI), “Reconciliation is a process of identifying the 

most accurate list of all medications a patient is taking — including name, dosage, frequency, and route —

and using this list to provide correct medications for patients anywhere within the health care system. 

Reconciliation involves comparing the patient’s current list of medications against the physician’s admission, 

transfer, and/or discharge orders. Experience from hundreds of organizations has shown that poor 

communication of medical information at transition points is responsible for as many as 50 percent of all 

medication errors and up to 20 percent of adverse drug events in the hospital. Each time a patient moves 

from one setting to another, clinicians should review previous medication orders alongside new orders and 

plans for care, and reconcile any differences. If this process does not occur in a standardized manner 

designed to ensure complete reconciliation, medication errors may lead to adverse events and harm.”

The IHI and its members have dedicated many resources to addressing the issues inherent in medication 

reconciliation, and the 5 Million Lives Campaign was created, which aims to protect five million lives from 

harm. Please see Appendix C for a copy of this guide.

(All taken from www.jointcommission.org 1/26/11)

December 7, 2010

The Joint Commission is committed to improving health care safety. This commitment is inherent in its 

mission to continuously improve the safety and quality of care provided to the public through the provision 

of health care accreditation and related services that support performance improvement in health care 

organizations. At its heart, accreditation is a risk-reduction activity; compliance with standards is intended to 

reduce the risk of adverse outcomes. 

The Joint Commission has identified a number of goals and measures that an institution must comply with in 

order to receive accreditation. These include National Patient Safety Goals.

National Patient Safety Goal (NPSG) 8 specifically addressed medication reconciliation:

“Accurately and completely reconcile medications across the continuum of care.”

NPSG 8 was published, but not enforced due to industry concerns about implementation, until December 

2010, when a new goal was published. Please see Appendix A for the complete goal.
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The Joint Commission Board of Commissioners has approved revisions to the National Patient Safety Goal 

(NPSG) on reconciling medication information (was NPSG.08.01.01 but is now NPSG.03.06.01), effective July 

1, 2011 (emphasis added) for the ambulatory, behavioral health care, critical access hospital, home care, 

hospital, long term care, and office-based surgery accreditation programs. The new, streamlined and focused 

version of the NPSG places a spotlight on critical risk points in the medication reconciliation process.

The NPSG was revised based on input from the field about difficulties with implementation of the 2009 

version of the NPSG because it was too prescriptive and detailed. In January 2009, The Joint Commission took 

action to reduce the burden of the NPSG on medication reconciliation for organizations and determined that 

survey findings would not be factored into the organization’s accreditation decision until a revised NPSG was 

developed. The revised NPSG underwent a field review in the second quarter of 2010; the review reaffirmed 

that medication reconciliation is an important patient safety issue that should continue as a NPSG. Please 

note that NPSG.03.06.01 replaces Goal 8 (08.01.01, 08.02.01, 08.03.01 and 08.04.01) and its related elements 

of performance. 

Following are the specific details of the Joint Commission’s National Patient Safety Goal for medication 

reconciliation, with notations as to where standards can support and enable achievement of this goal.

National Patient Safety Goal on Reconciling Medication Information

NPSG.03.06.01

Elements of Performance for NPSG.03.06.01

 Obtain and/or update information on the medications the patient is currently taking. This information 

is documented in a list or other format that is useful to those who manage medications.

o Note 1: The organization obtains the patient's medication information at the beginning of an 

episode of care. The information is updated when the patient's medications change. (MedHx)

o Note 2: Current medications include those taken at scheduled times and those taken on an 

as-needed basis. See the Glossary for a definition of medications. (opportunity to add data 

elements, i.e. Sig, to MedHx?)

o Note 3: It is often difficult to obtain complete information on current medications from the 

patient. A good faith effort to obtain this information from the patient and/or other sources 

will be considered as meeting the intent of the EP.

 Define the types of medication information to be collected in different settings and patient 

circumstances.

o Note 1: Examples of such settings include primary care, urgent and emergent care, 

ambulatory surgery, convenient care, outpatient radiology, and diagnostic settings. (MedHx)

o Note 2: Examples of medication information that may be collected include name, dose, route, 

frequency, and purpose. (MedHx) (opportunity to add data elements, i.e. Sig, to MedHx?)

 For organizations that prescribe medications: Compare the medication information the patient 

brought to the organization with the medications ordered for the patient by the organization in order 

to identify and resolve discrepancies.

o Note 1: Discrepancies include omissions, duplications, contraindications, unclear information, 

and changes. A qualified individual, identified by the organization, does the comparison. (See 

also HR.01.06.01, EP 1) (This will require manual effort until more information is available to 
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be transmitted electronically, in a codified manner. At such point, programs should be able to 

identify the discrepancies. Encouraging the use of the MedHx transaction now will likely 

mean an easier transition when RxNorm and Sig are widely used.)

 For organizations that prescribe medications: Provide the patient (or family as needed) with written 

information on the medications the patient should be taking at the end of the episode of care (for 

example, name, dose, route, frequency, purpose). (CCD)

o Note: When the only additional medications prescribed are for a short duration, the 

medication information the organization provides may include only those medications. For 

more information about communications to other providers of care when the patient is

discharged or transferred, refer to Standard PC.04.02.01.

 For organizations that prescribe medications: Explain the importance of managing medication 

information to the patient at the end of the episode of care.

o Note: Examples include instructing the patient to give a list to his or her primary care 

physician; to update the information when medications are discontinued, doses are changed, 

or new medications (including over-the-counter products) are added; and to carry medication 

information at all times in the event of emergency situations. (For information on patient 

education on medications, refer to Standards MM.06.01.03, PC.02.03.01, and PC.04.01.05.) 

(The patient can be given a list to give to the next provider of care, but can also be 

encouraged to have that next provider use the MedHx transaction. Still unaddressed is the 

role of PHRs in the exchange of data, and this may be critical if OTC use is not tracked in an 

EHR.)

C. Medication Reconciliation Process Background

The medication reconciliation process varies by setting, and the participants can include administrative staff, 

who may compile the data, patients/caregivers to validate current regimen/actual practice, and clinicians 

who review for appropriateness.

Accomplishing Medication Reconciliation

“While the importance of medication reconciliation is universally recognized, there is no consensus on the 

best method of carrying out the process of reconciling medications. A variety of methods have been studied, 

including having pharmacists perform the entire process, linking medication reconciliation to existing 

computerized provider order entry systems, and integrating medication reconciliation within the electronic 

medical record system. Another avenue being explored is involving patients in reconciling their own 

medications.

The evidence supporting patient benefits from reconciling medications is relatively scanty. Interventions led 

by pharmacists or utilizing information technology have reduced actual and potential medication errors, but 

as yet, no system has resulted in an improvement in clinical outcomes. The effect of electronic systems and 

nurse-led processes has yet to be determined.”

(AHRQ PSNet Patient Safety Primer Page 1 http://psnet.ahrq.gov/printviewPrimer.aspx?primerID=1 

1/2/2011)
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D. Overview of Medication Reconciliation Challenges at Transfer of Care

(REPRINTED) ARCH INTERN MED/VOL 164, MAR 8, 2004 WWW.ARCHINTERNMED.COM

Adverse Events Due to Discontinuations in Drug Use and Dose Changes in Patients Transferred Between 

Acute and Long-term Care Facilities

Kenneth Boockvar, MD, MS; Eliot Fishman, PhD; Corinne Kay Kyriacou, PhD; Anna Monias, MD; Shai Gavi, 

MD; Tara Cortes, PhD

Studies have shown that unintended changes in medications occur in 33% of patients at the time of 

transfer from one site of care within a hospital, and in 14% of patients at hospital discharge.

In the United States, where older adults are routinely transferred among multiple sites of care, little 

is known about how relocation affects patient health. In this sample of individuals transferred 

between nursing home and hospital, discontinuations of use and dose changes in existing 

medications on hospital admission, during the hospital stay, and on nursing home readmission were 

implicated in causing ADEs. The incidence of ADEs measured in this study (20%) exceeded that found 

in studies of ADEs occurring during episodes of care within acute or long-term care facilities,7,8 

although the severity of ADEs seemed to be less.

Our study suggests that alterations in medication prescribing are common during transfer between 

institutions and are a cause of ADEs. Clinicians may alter or discontinue medication use at the time of 

hospital or nursing home admission as a result of changes in a patient’s clinical condition or to adhere 

to institutional formulary requirements. Clinicians may also temporarily discontinue medication use 

at the time of hospital admission if they believe it is contraindicated or inessential to acute care. In 

this study, it is not surprising that the frequency of medication change observed on hospital 

admission was greater than that observed on return to the nursing home, because the time of 

hospital admission is typically a time of greater change in patient clinical status and a time of in-detail 

assessment of medication use.

A proportion of transfer-related medication changes and ADEs may occur because of inaccurate or 

incomplete communication of medication regimens between facilities.

Because most nursing homes and hospitals are loosely affiliated and do not share medical records, 

medication ordering systems, formularies, or pharmacies (as was the case for institutions that 

participated in this study), medication information may be inaccurately transcribed.

Of note, although medication changes implicated in causing ADEs occurred in both directions of 

transfer and during the hospital stay, in most cases the ADE occurred after the study participant 

returned to the nursing home. This is in part because the interval from a hospital-based medication 

change to an ADE was greater than the duration of hospital stay. This result suggests that an 

intervention implemented at the time of nursing home readmission has the potential to prevent 

most ADEs. Such an intervention might identify and rectify medication changes that occur during 

hospitalization that have potential for harm, perhaps using the input of a clinical pharmacist. In 

addition, a proportion of ADEs may be prevented by systems-level interventions. Improved transfer 
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documentation or telephone communication at the time of transfer may prevent a proportion of 

inadvertent medication changes and ADEs. Institutions between which patients are frequently 

transferred might make efforts to minimize formulary-driven medication changes to reduce the 

number of medication changes that lack clinical rationale. Finally, Department of Veterans Affairs 

health facilities have an electronic medical record that is accessible to practitioners in inpatient, 

outpatient, and long-term care settings. Research is needed to determine if such a shared electronic 

medical record can improve the accuracy of inter-institutional communication of medication 

information, prevent errors that occur from handwritten transcribing, and prevent relocation-related 

ADEs.

Appendix B contains information from the Institute for Healthcare Improvement that provides 

recommendations/guidance on process design for medication reconciliation at various transition points.
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E. Information Exchange Standards and Medication Reconciliation

Medication History (NCPDP SCRIPT RXHREQ, RXHRES)

The NCPDP SCRIPT Medication History message is the most common form in which medication history 

information is shared between a patient’s pharmacy benefit insurer and their physician or other practitioner. 

The SCRIPT Medication History format is named by CMS for use in the care of Medicare Part D recipients, and 

is required for participation in the federal MIPPA e-prescribing incentive program for practitioners.

The 8.1 version of the standard is in most common use today, though use of the 10.6 version is also allowed 

by federal programs; the industry is expected to implement the 10.6 version over the course of the upcoming 

2-4 years. 

This analysis will focus on the 10.6 version of the standard, which contains a combination of free-text and 

codified medication content. 

Continuity of Care Record (ASTM CCR)

The Continuity of Care Record, or CCR, is a patient medical summary format managed by ASTM International. 

It represents a core data set of the most relevant facts about a patient’s health care. The CCR standard predates, and provided the clinical content model, for the Continuity of Care Document—which was created in 

conjunction with HL7. The CCR has continued to evolve since the creation of the CCD, though the content of 

the two formats remains very similar. Meaningful Use rules allow use of the ASTM E2369 Standard 

Specification for Continuity of Care Record.

Medication content in the CCR is held in its Medications section, which is used to list and describe the 

patient’s current medications and pertinent medication history. According to the CCR implementation guide, 

“at a minimum, the currently active medications should be listed, with an entire Medication History as an 

option, particularly when the CCR is used for comprehensive data export.”

The Medications section allows for a mix of codified and free-text content.

Continuity of Care Document (HL7 CCD)

The CCD is a patient summary format based on the clinical information contained in the Continuity of Care 

Record and the HL7 Clinical Document Architecture (CDA) electronic document structure. As such, it’s 

content is very similar to that of the CCR, though not identical—as the two standards have evolved since the 

creation of the CCD. Meaningful Use rules identify the following as the CCD version and implementation 

guidance: HITSP (Healthcare Information Technology Standards Panel) Summary Documents Using HL7 CCD 

Component HITSP/C32.

A key characteristic of the CCD is that content can be represented as unstructured text alone, which can 

optionally be accompanied by structured and codified content. The CDA specifies that the content of the

document consists of a mandatory textual part (which ensures human interpretation of the document 

contents) and optional structured parts (for software processing).
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Prescription Fill Status (NCPDP SCRIPT RXFILL)

The NCPDP SCRIPT Fill Status message enables the dispensing pharmacy to notify the prescriber when a 

prescription is dispensed and picked up by (or delivered to) the patient. The message also enables the 

prescriber to be notified if the order can’t be dispensed or if the patient does not take possession of the 

medication.

The standard is not in wide use today—with initial usage primarily in the long-term and post-acute care 

settings. However, the standard is named for optional use by CMS for Medicare Part D patients, and its 

potential value in the ambulatory setting to alert prescribers of non-compliance by their patients has been 

noted. 

Similar to dispense-based medication history provided by healthcare payers, the Fill Status can augment 

EMR-based medication information, which typically reflects medication orders which may or may not have 

actually been filled and picked up by the patient.

The section below provides a high-level comparison of the information content and use of these standards.
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F. High-level Comparison of Medication Concepts in SCRIPT, HL7 CCD, and CCR

Below is an overview of how medication content is captured in the standards mentioned above.

Standard

Concept

SCRIPT 10.6 Medication 

History 

ASTM Continuity of Care 

Record (ASTM E2369)

HITSP C/32 Continuity of 

Care Document

SCRIPT 10.6 

Fill Status

Section of standard Medication Dispensed Medications Medications Medication Dispensed

Prescribed versus dispensed

Prescribed versus 

dispensed medication

In its typical usage, the 

standard conveys only 

dispensed medications. 

Data sources that 

respond to the message 

(e.g., PBMs and health 

plans) typically only have 

a view of dispensed 

prescription medications 

In its typical usage, 

medications prescribed

for the patient—as 

captured in the 

practitioner’s electronic 

medical record—are 

conveyed in the 

standard.

In its typical usage, 

medications prescribed

for the patient—as 

captured in the 

practitioner’s electronic 

medical record—are 

conveyed in the 

standard.

Reflects medications 

dispensed (or not 

dispensed or not picked 

up by the patient) 

Prescriber

Prescribing clinician Optional. Typically is 

included with each 

medication

A prescriber is not 

associated with each 

individual medication

Optional The ordering prescriber 

is identified with the 

subject medication

Pharmacy

Dispensing pharmacy Required Optional. Not typically 

included if source is EMR

Optional. Not typically 

included if source is EMR

Required

Dates / Status

Prescribed date Optional Optional Optional Required

Dispensed date Required

Note that each 

dispensing event is 

included as a separate 

item. E.g., a maintenance 

med dispensed monthly 

would result in 12 

records in the medication 

history message

Not applicable when CCR 

is generated from an 

EMR

Not applicable when CCR 

is generated from an 

EMR

Date of dispensing is 

required (if the 

medication was 

dispensed) 
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Standard

Concept

SCRIPT 10.6 Medication 

History 

ASTM Continuity of Care 

Record (ASTM E2369)

HITSP C/32 Continuity of 

Care Document

SCRIPT 10.6 

Fill Status

Administration start / 

end dates

Optional. Not typically 

included in ambulatory 

settings

Optional Required Optional. Not typically 

included in ambulatory 

settings

Drug status (e.g., Active, 

on-hold, prior history / 

no longer active)

Not supported. Recipient 

must consider dispense 

dates and discuss with 

the patient whether a 

medication is currently 

being taken

Optional Represented in start/end 

dates

Not supported

Indication

Indication /diagnosis Optional. Not typically 

included

Terminology: ICD-9 (used 

today), ICD-10, others 

allowed

Optional. Terminology: 

“Problems should be 

coded at the highest 

level using

SNOMED CT and the 

most recent ICD-9 CM 

codes at the time

the CCR is generated”

Optional. Terminology: 

VA/KP Problem List 

Subset of SNOMED CT

Optional. Not typically 

included

Terminology: ICD-9 (used 

today), ICD-10, others 

allowed

Medication

Textual drug description Textual drug description 

containing 

 drug name

 strength / unit of 

measure

 dose form 

Product name required 

(e.g., Amoxicillin). 

Strength, form are 

optional

Required Textual drug description 

containing 

 drug name

 strength / unit of 

measure

 dose form 

Coded medication Optional. Terminology:

 11-digit NDC typically 

included today

 RxNorm is expected to 

be adopted for this 

use, but in not typically 

included today

Optional. Terminology:

 RxNorm is 

recommended

 NDC is allowed

Required. Terminology: 

RxNorm for brand 

names/clinical drugs and 

NDC for packaged 

products

Optional. Terminology:

 11-digit NDC typically 

included today

 RxNorm is expected to 

be adopted for this 

use, but in not typically 

included today
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Standard

Concept

SCRIPT 10.6 Medication 

History 

ASTM Continuity of Care 

Record (ASTM E2369)

HITSP C/32 Continuity of 

Care Document

SCRIPT 10.6 

Fill Status

Coded strength Optional. Terminology: 

NCIt NCPDP subset –

Strength Unit Of

Measure

Optional. Terminology 

not specified

Optional Optional. Terminology: 

NCIt NCPDP subset –

Strength Unit Of

Measure

Coded dose form Optional. Terminology: 

NCIt NCPDP subset 

Optional. Terminology 

not specified

Optional. Terminology: 

NCIt

Optional. Terminology: 

NCIt NCPDP subset -

Drug Strength Form

Quantity

Quantity prescribed Optional. Not typically 

included

Optional Required. Terminology: 

NCIt presentation units 

or UCUM 

Required

Quantity dispensed Optional. Typically 

included today. 

Terminology: NCIt NCPDP

subset: Quantity Unit of 

Measure

Optional Optional Required (if drug was 

dispensed)

Days supply Optional Optional Optional Optional

Refills allowed Optional Optional Optional Optional

Administration / dosing directions

Textual administration 

directions (sig)

Required Optional Required Required

Codified administration 

directions

Optional. Not widely 

implemented today; 

adoption timing 

unknown

Not supported Optional. Terminology: 

Dose quantity: UCUM 

(Unified Code for Units of 

Measure). 

Optional. Not widely 

implemented today; 

adoption timing 

unknown

Alerts

Patient allergies or 

intolerances

Not supported Optional. “At a minimum, 

currently active and any

relevant historical 

allergies, adverse

reactions, and alerts 

should be listed.”

Required Not supported
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Standard

Concept

SCRIPT 10.6 Medication 

History 

ASTM Continuity of Care 

Record (ASTM E2369)

HITSP C/32 Continuity of 

Care Document

SCRIPT 10.6 

Fill Status

Drug interactions or 

other conflicts identified 

at the time of prescribing 

(e.g., potential drug 

interaction)

Optional. Not typically 

included. Terminology:

Not standards-based

Not supported Not supported. Optional to include 

interactions identified 

during dispensing. Not 

typically included. 

Terminology: Not 

standards-based

Other

Fulfillment instructions 

(e.g., substitutions 

allowed, dispense as 

written)

Optional Optional Optional Optional.

Note that the actual 

dispensed product is 

included...indicating 

when substitution occurs
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G. Summary of Support, Challenges and Opportunities

Two key challenges related to the support of medication reconciliation processes by the above-referenced 

information exchange standards are:

 inconsistent use of coded terminologies—making automated linking and de-duplication of 

medication information difficult

 the different perspectives of the CCD and CCR versus the NCPDP Medication History message, where 

the CCD and/or CCR represent ordered and historical patient medications, and the Medication 

History reflects only dispensed medications.

The sections below describe these challenges in more detail. 

Note: A later project deliverable will further explore compatibility between the CCD, CCR, and Medication 

History standards. 

Coded Terminology

The three standards reviewed vary with regard to:

 the level of support for coded terminology (the extent to which clinical content is able to be captured 

in a standardized coded form in the standard)

 the particular coded terminologies supported, and

 whether coded terminology is required or optional for different clinical concepts—impacting whether 

a recipient can rely on receiving coded content.

SCRIPT 10.6 Medication History. The SCRIPT 10.6 standard enables codification of drug name, strength, dose 

form, quantity and directions. However, in the Medication History message, coded content is not required for 

any of these concepts and is typically not included by implementers today. 

 When codified, medication products are typically identified using the NDC 11 of the dispensed 

product, with RxNorm expected to be used for drug identification in the future. 

 Drug strength, dose form and quantity are coded using a subset of the National Cancer Institute’s NCI 

Thesaurus, which can be translated to related terminologies through the NCI Metathesaurus.

 Diagnoses are allowed but not typically included in Medication History messages. When present, they 

can be coded using ICD-9 or ICD-10, though ICD-9 is typically used today. Allergy information is not 

supported in the Medication History message.

 Codification of administration directions is made possible using the Structured Sig segment, which is 

a relatively new addition to the SCRIPT standard that has not yet been adopted by the industry. 

Clinical concepts within this segment are primarily coded using SNOMED or FMT (Federal Medication 

Terminologies) terms.

CCR. The CCR enables capture of coded clinical concepts, but does not require their use nor does it limit the 

terminologies used. From the CCR E2369 implementation guide: “Detailed coding is recommended whenever 

practical within the CCR. In all instances, the coding system and version must be specified. Specific coding 
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recommendations (for the U.S.) include the following (note that these are coding suggestions and are nonnormative)... ”

 When codified, medication products are to be identified using RxNorm codes, with NDC codes used 

as an optional, secondary identifier. Separate codification of drug strength, dose form and quantity 

does not appear to be supported.

 Diagnoses are recommended to be coded using SNOMED and ICD-9.

 Administration directions can be captured in a structured form, but it does not appear that 

component concepts (e.g., “twice daily”) can be codified using a standard terminology such as 

SNOMED.

CCD / C32. The HITSP C32 implementation directions for the Continuity of Care Document (CCD) requires the 

presence of coded content in addition to human-readable text. 

 Medications are to be identified using RxNorm codes, with NDC codes used to specify particular drug 

products / packages. 

 Diagnoses are recommended to be coded using the VA/KP Problem List Subset of SNOMED CT

 Administration directions can be captured in a structured form

Linking Ordered and Dispensed Medications

A key challenge in integrating medication information from the three formats discussed above is that the 

SCRIPT Medication History reflects dispensed medications that have been dispensed, while the CCD and CCR 

primarily represent current ordered medications and optionally historical medications reported by the patient 

or another provider. 

When integrating information from a Medication History and a CCD or CCR, the receiver matches the ordered 

medications to the related dispensing event(s), and must be careful not to “double count” medications 

present in both sources. In addition, there may be differences in how a given medication is reported between 

the order and dispensing event, including:

 brand versus generic—for example if a branded medication is ordered but fulfilled using a generic 

substitute

 strength / quantity—for example if the order specifies “30 tablets. Take 1 20mg tablet daily” and the 

pharmacy dispenses 60 10mg tablets instead, with patient instructions to take 2 10mg tablets daily

 multiple dispensing for a single order—for example where a maintenance medication is dispensed 

twelve times per year based on a single order.

As noted above, the different standards allow for different coded drug references—making it difficult to 

reliably match up and “de-duplicate” ordered and dispensed medications. Today, prescribing systems use a 

combination of drug identifier comparison (primarily NDCs) and drug name matching to accomplish this task.

However, linking orders to fulfillment details provides an opportunity to identify situations where a 

medication is dispensed inappropriately, for example in the case where a patient alters a narcotic 
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prescription to specify a higher quantity, or obtains prescriptions from other prescribers and brings them to 

multiple pharmacies to be dispensed.
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Appendix A –Joint Commission’s National Patient Safety Goal for Medication 

Reconciliation (prior version)

NPSG.08.01.01

A process exists for comparing the patient’s current medications with those ordered for the patient while 

under the care of the organization.

Rationale

Patients are at high risk for harm from adverse drug events when communication about medications is not 

clear. The chance for communication errors increases whenever individuals involved in a patient’s care 

change. Communicating about the medication list, making sure it is accurate, and reconciling any 

discrepancies whenever new medications are ordered or current medications are adjusted are essential to 

reducing the risk of transition-related adverse drug events.

Elements of Performance

1. At the time the patient enters the organization or is admitted, a complete list of the medications 

the patient is taking at home (including dose, route, and frequency) is created and documented. 

The patient and, as needed, the family are involved in creating this list.

2. The medications ordered for the patient while under the care of the organization are compared 

to those on the list created at the time of entry to the organization or admission.

3. Any discrepancies (that is, omissions, duplications, adjustments, deletions, additions) are 

reconciled and documented while the patient is under the care of the organization.

4. When the patient’s care is transferred within the organization the current provider(s) informs the 

receiving provider(s) about the up-to-date reconciled medication list and documents the 

communication. Note: Updating the status of a patient’s medications is also an important 

component of all patient care hand-offs.

NPSG.08.02.01

When a patient is referred to or transferred from one organization to another, the complete and reconciled 

list of medications is communicated to the next provider of service, and the communication is documented. 

Alternatively, when a patient leaves the organization’s care to go directly to his or her home, the complete 

and reconciled list of medications is provided to the patient’s known primary care provider, the original 

referring provider, or a known next provider of service.

Note: When the next provider of service is unknown or when no known formal relationship is 

planned with a next provider, giving the patient and, as needed, the family the list of reconciled 

medications is sufficient.

Elements of Performance 

1. The patient’s most current reconciled medication list is communicated to the next provider of 

service, either within or outside the organization. The communication between providers is 

documented.
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At the time of transfer, the transferring organization informs the next provider of service how to 

obtain clarification on the list of reconciled medications

NPSG 08.03.01

When a patient leaves the organization’s care, a complete and reconciled list of the patient’s medications is 

provided directly to the patient and, as needed, the family, and the list is explained to the patient and/or 

family.

Rationale

The accurate communication of the patient’s medication list to the patient and, as needed, the 

family, reduces the risk of transition related adverse drug events. A thorough knowledge of the 

patient’s medications is essential for the patient’s primary care provider or next provider of service to 

manage the subsequent stages of care for the patient.

Elements of Performance 

1. When the patient leaves the organization’s care, the current list of reconciled medications is 

provided and explained to the patient and, as needed, the family. This interaction is documented. 

Note: Patients and families are reminded to discard old lists and to update any records with all 

medication providers or retail pharmacies.

NPSG 08.04.01

In settings where medications are used minimally, or prescribed for a short duration, modified medication 

reconciliation processes are performed.

Note: This requirement does not apply to organizations that do not administer medications. It may 

be important for health care organizations to know which types of medications their patients are 

taking because these medications could affect the care, treatment, or services provided.

Rationale

A number of patient care settings exist in which medications are not used, are used minimally, or are 

prescribed for only a short duration. This includes areas such as the emergency department, urgent 

and emergent care, convenient care, office-based surgery, outpatient radiology, ambulatory care, 

and behavioral health care. In these settings, obtaining a list of the patient’s original, known, and 

current medications that he or she is taking at home is still important; however, obtaining 

information on the dose, route, and frequency of use is not required.

Elements of Performance

1. The organization obtains and documents an accurate list of the patient’s current medications and 

known allergies in order to safely prescribe any setting-specific medications (for example, local 

anesthesia, antibiotics) and to assess for potential allergic or adverse drug reactions.
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2. When only short-term medications (for example, a pre-procedure medication or a short-term course 

of an antibiotic) will be prescribed and no changes are made to the patient's current medication list, 

the patient and, as needed, the family are provided with a list containing the short-term medication 

additions that the patient will continue after leaving the organization. Note: This list of new shortterm medications is not considered to be part of the original, known, and current medication list. 

When patients leave these settings, a list of the original, known, and current medications does not 

need to be provided, unless the patient is assessed to be confused or unable to comprehend 

adequately. In this case, the patient’s family is provided both medication lists and the circumstances 

are documented.

3. In these settings, a complete, documented medication reconciliation process is used when: Any new 

long-term (chronic) medications are prescribed.

4. In these settings, a complete, documented medication reconciliation process is used when: There is a 

prescription change for any of the patient’s current, known long-term medications.

5. In these settings, a complete, documented medication reconciliation process is used when: The 

patient is required to be subsequently admitted to an organization from these settings for ongoing 

care.

When a complete, documented, medication reconciliation is required in any of these settings, the complete 

list of reconciled medications is provided to the patient, and their family as needed, and to the patient’s 

known primary care provider or original referring provider or a known next provider of service.
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Appendix B: Institute for Healthcare Improvement – Medication Reconciliation 

Process

Reconcile Medications at All Transition Points:

Reconcile Medications in Outpatient Settings

http://www.ihi.org/IHI/Topics/PatientSafety/MedicationSystems/Changes/IndividualChanges/ReconcileMedicationsinOutpatientSettings.htm

It is important for outpatient areas of hospitals and hospital-based clinics (such as outpatient surgery, dialysis 

facilities, outpatient oncology clinics, and family practice areas) to reconcile medications at each visit. 

The process for reconciling medications in outpatient settings (including the Emergency Department for 

patients who are not admitted) is a bit different than the process for inpatient transitions.

First, a medication list must be collected. It is important to know what medications the patient has been 

taking or receiving prior to the outpatient visit in order to provide quality care. This applies regardless of the 

setting from which the patient came — home, long-term care, assisted living, etc. 

The medication list should include all medications (prescriptions, over-the-counter, herbals, supplements, 

etc.) with dose, frequency, route, and reason for taking it. It is also important to verify whether the patient is 

actually taking the medication as prescribed or instructed, as sometimes this is not the case.

At the end of the outpatient visit, a clinician needs to verify two questions:

1. Based on what occurred in the visit, should any medication that the patient was taking or receiving 

prior to the visit be discontinued, altered, or held pending consultation with the prescriber? 

2. Have any new prescriptions been added today?

These questions should be reviewed by the physician who completed the procedure when one occurs, or the 

physician who evaluated and treated the patient.

If the answer to both questions is “no,” the process is complete.

If the answer to either question is “yes,” the patient needs to receive clear instructions about what to do —

all changes, holds, and discontinuations of medications should be specifically noted. Include any follow-up 

required, such as calling or making appointments with other practitioners and a timeframe for doing so.

When patients are recurring outpatients, a medication list can be kept on file rather than re-created on every 

visit. Each time the patient comes for a visit, the list should be re-verified for any additions, deletions or 

changes to medications, doses, frequencies, routes and alterations from original prescription or instructions.

Reconcile Medications at All Transition Points:

Reconcile Discharge Orders with the Nursing Medication Administration Record

http://www.ihi.org/IHI/Topics/PatientSafety/MedicationSystems/Changes/IndividualChanges/Reconcile+Discharge+Orders+with+the+Nursing+Medic

ation+Administration+Record.htm

After discharge from the hospital, a patient may continue taking some medications at home, but not perhaps 

all of them. Therefore, it is extremely important to compare the discharge medication orders with the nursing 

medication administration record (MAR) to check for any discrepancies. If a medication the patient has been 
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receiving in the hospital is not in the discharge orders, and there is no adequate documentation indicating 

why that medication has been omitted, then a nurse or pharmacist should contact the patient’s physician to 

verify whether or not the patient should discontinue use of the medication. 

Tips

 Create a standardized form that lists all the medications the patient has been receiving in the 

hospital, and include space on the form for physicians to document the reasons for omitting certain 

medications upon discharge from the hospital. Physicians can also use this form for ordering 

medications. 

 Attach the pre-admission medication list to the discharge orders form — the patient may need to 

discontinue some medications that were being taken at home. 

 Provide the patient with a comprehensive list of all medications — those being taken before 

admission plus the new medications from the discharge orders. Clearly indicate the name of each 

drug, its purpose, and the instructions for taking the medication, as well as any instructions for 

discontinuing use.