Medical Reconciliation and Documentation Definition Medication Reconciliation is

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Medical Reconciliation and Documentation

Medical Reconciliation and Documentation

Definition • Medication Reconciliation is a process of obtaining a list of the patient’s

Definition • Medication Reconciliation is a process of obtaining a list of the patient’s current medications, including the name of the drug, dosage, route, frequency and time of last dose. • Medications must be reconciled upon admission, transfer within the hospital to another level of care, going to surgery, and at discharge.

Medical Reconciliation • A medication and allergy history is obtained by the medical provider

Medical Reconciliation • A medication and allergy history is obtained by the medical provider from the patient and/or family members who are present at the time the patient presents for care, or at the time of admission. • The medication history should include a complete list of prescription and non-prescription medications: • • • Over-the-counter medications Patches Inhalers Ear/eye/nose drops Dietary supplements

Medical Reconciliation (cont. ) • The medical provider should determine if the medication history

Medical Reconciliation (cont. ) • The medical provider should determine if the medication history is being obtained from a reliable source. • • • The patient’s current pharmacy The patient’s physician’s office or clinic The patient’s long-term care facility or home care records Transfer forms from another facility Recent hospital discharge forms • The source of the medication history must be recorded in the patient’s medical record.

When do you do Med Rec? • Once upon patient admission, to reconcile what

When do you do Med Rec? • Once upon patient admission, to reconcile what he or she was taking, • Again when ordering his or her meds, to reconcile what he or she is taking in the hospital, • And once more upon transfer and discharge, to reconcile what he or she will be taking.

Documenting HDS Usage • Use the same technique and detail as with medications. •

Documenting HDS Usage • Use the same technique and detail as with medications. • This will include information about: • • Constituents, plant species Name of product Brand, manufacturer Dosage and duration Frequency of use, when used Purpose Cost of each HDS used

Barriers to Medical Reconciliation and Documentation • Patient knowledge about medications limited • Electronic

Barriers to Medical Reconciliation and Documentation • Patient knowledge about medications limited • Electronic medical records • Fragmentation of care • Time constraints

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End of Presentation

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