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Medication Reconciliation (6.1.10)

Medication Reconciliation (6.1.10) - Policies, Clinical, UW Health Clinical, Medications and Pharmacy

6.1.10


UW HEALTH CLINICAL POLICY 1
Policy Title: Medication Reconciliation
Policy Number: 6.1.10
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: January 27, 2017


I. PURPOSE

To accurately and completely reconcile medications across the continuum of care.

II. DEFINITIONS

A. Medication.
Includes any of the following: prescription medications; sample medications; herbal remedies, vitamins, or
nutraceuticals; over-the-counter medications; vaccines; diagnostic and contrast agents used on or
administered to persons to diagnose, treat, or prevent disease or other abnormal conditions; radioactive
medications; respiratory therapy treatments; parenteral nutrition; blood derivatives; intravenous solutions;
and any product designated by the FDA as a drug. This definition does not include enteral nutrition
solutions, which are considered food products, oxygen, and other medical gases.
B. Medication Reconciliation.
Medication reconciliation is the process of identifying the most complete and accurate list of medications a
patient is taking and using this list to provide correct medications for the patient anywhere within the
organization. The process includes comparing prescriber's medication orders at the interfaces of care to that
list, bringing discrepancies to the prescriber's attention, and if appropriate making changes to the orders
including omissions, duplications, interactions and name/dose/route confusion. Other steps in medication
reconciliation include updating the medication list as orders change during the episode of care and
communicating the updated list to the patient and the next known provider of care.
C. Relevant sites of care.
The relevant sites of care are all areas where the patient's response to the treatment or service could be
affected by the medications the patient has been taking, particularly those areas where medications are
prescribed or administered, including inpatient units, ambulatory clinics, emergency department, operating
room, procedure areas, and home health care services.
D. Minimal use sites of care.
Minimal use site sites of care are all areas where medications are used minimally or not at all. In these
settings, the minimal amount of information needed to safely administer medications must be collected prior
to administering medication or providing therapy. The type of information collected is defined and
documented by the clinic or procedure area providing care.
E. Discharge medication list.
The list of all medications the patient is to continue taking upon discharge. This is not an order, rather a
complete list of continuing medications. This list should include all routine medications for the patient,
including clinic-administered medications.
F. Authorized personnel.
The authorized personnel include nurses, physicians, physician assistants, nurse practitioners, pharmacists,
medical assistants, radiology technicians, and other designated staff by location.

III. POLICY ELEMENTS

A complete list of a patient's current medications, allergies, and medication sensitivities will be obtained and
documented upon admission to the organization in all relevant sites of care and all settings, including
inpatient units, ambulatory clinics, emergency department, operating room, procedure areas and home
health care services provided at UW Health. This is reviewed and updated at all visits whenever medications
are administered, prescribed, or the response to the care or service provided to the patient could be affected
by medications.

All new medications prescribed or administered will be reconciled against this list during the patient's care.
Inpatients transferred between services or levels of care will have all medications reconciled. If a new
medication is prescribed (or changes are made to the current regimen), the patient's electronic medication
list is then updated and a copy of the updated list is provided to the patient.




UW HEALTH CLINICAL POLICY 2
Policy Title: Medication Reconciliation
Policy Number: 6.1.10

A complete list of medications will be given to the patient upon discharge from the organization, and be
made available to the next known provider or service when the patient is referred or transferred to another
setting, service, practitioner, or level of care within or outside the organization.

IV. GENERAL PROCEDURE

A. In relevant sites of care, a complete list of a patient's current medications, allergies, and medication
sensitivities must be obtained and documented upon admission to the organization. This list is updated at all
visits whenever medications are used or the response to the care or service provided to the patient could be
affected by medications.
B. In minimal use sites of care, modified medication reconciliation process will be performed if an area
consistently meets the following requirements for at least 80% of patient encounters:
i. Medications are not administered during the patient encounter **OR**
ii. Medications are used, but use is minimal. Examples of “minimal medication use” include topical
fluoride applications, local infiltration of lidocaine for suturing lacerations, enteric barium for imaging
studies, or when medications act locally with little systemic effect (for example, dexamethasone
applied for iontophoresis) **AND**
iii. No changes to the patient’s chronic list of medications are made **AND**
iv. No new medications are prescribed for or provided to the patient for use after discharge that are
intended for chronic use (greater than 14 days) **AND**
v. The patient is not admitted for continuation of care **AND**
vi. Full reconciliation processes are expected for all encounters unless authorized in writing by the
chair of the regulatory, external reporting and compliance committee.
C. If a list of the patient's medications cannot be obtained from the patient because of patient factors limiting
their ability to provide this information at the time of the encounter, documentation of why this list could not
be obtained should occur.
i. The medication list should be the most accurate and current history that can be obtained at the
time of the encounter. Providers should note the informant within the clinical record
(Family/Guardian, Nursing Home, Other Health Care Facility, Patient, Pharmacy, UW Records).
D. In all settings, the patient's list of medications must be updated and provided to the patient whenever a new
medication is prescribed or recommended for the patient. The list must also be provided directly either
through documentation or other communication to the next known providers of care for the patient.
E. The patient's list of medications should include all medications the patient will be taking after the encounter.
This often includes medications not prescribed by the practitioner responsible for the encounter and does
not signify that the practitioner of record for the encounter has ordered or reordered all of the medications.

V. PROCEDURE FOR PATIENTS ADMITTED TO THE INPATIENT UNITS

The following applies for all inpatients as well as outpatient short stay and observation patients.

A. Admission.
i. Medication Histories:
a. A complete and accurate medication history will be obtained for all patients admitted to the
inpatient units and documented as a Clinical Pharmacist Medication History Admission
note in the clinical record by a pharmacist as soon as possible after admission, no later
than 24 hours after admission.
b. Patients may have their medication history obtained the day before a scheduled
admission.
c. The source of the information will be documented in the note.
d. If no information can be obtained from any source, the pharmacist will document "Patient
not able to be interviewed, no information available" in the Medication History Note.
e. In addition to the patient’s medication history, the pharmacist will document the following:
1. Indication for use for each medication.
2. The patient’s allergies/intolerance to drugs, food, latex, contrast, and
environmental allergies.
3. The date and approximate time the last dose of the medication was taken, if
known.
4. The patient’s preferred pharmacy.



UW HEALTH CLINICAL POLICY 3
Policy Title: Medication Reconciliation
Policy Number: 6.1.10

5. Weight and height, of the patient.
6. Functional limitations and or barriers to learning apparent to the pharmacist.
7. Adherence of patient and/or caregiver to taking the medications as prescribed
and if they are aware of the purpose of the therapy.
8. History of treatment with chemotherapy.
9. The pharmacist will identify non-formulary medications and work with other
providers to develop a plan for providing these medications if necessary during
hospitalization (e.g., use of patient’s own order or non-formulary drug order,
therapeutic interchange, or drug holiday).
f. For patients transferred from another acute care facility:
1. The pharmacist will document both current and pre-admission home medications
in the clinical record in the Medication History Admission note.
2. Medications new to the patient should be distinguished from those the patient
was taking prior to admission to the other care facility.
3. If patient is taking warfarin or low molecular weight heparin (LMWH) prior to
admission and followed by the UWHC anticoagulation service, the pharmacist
should contact the outpatient anticoagulation service to notify them of the
admission.
g. Medication Reconciliation:
1. Pharmacists will reconcile admission medication orders by comparing the orders
to the patient's home medication history immediately upon receipt of both
sources of information.
2. The pharmacist will contact the prescriber for clarifications regarding
discrepancies identified during the reconciliation. Discrepancies include when
any home medication is not ordered upon admission without a documented
reason, known therapeutic contraindication, or policy regarding their omission.
3. The pharmacist will generate a pharmacist medication reconciliation note in the
clinical record to document how discrepancies were addressed.
4. The pharmacist will document that medication reconciliation is completed in the
clinical record.
h. Patient Transfers:
1. Medication reconciliation will be performed whenever a patient transfers level of
care or service.
2. For inpatients, the patient's medication administration record (MAR) is available
to all of the patient's care providers. This may occur through online access to the
electronic MAR or through printing the MAR and placing it in the patient's chart
prior to transfer.
3. Pharmacists will reconcile the patient's new (transfer) medication orders versus
their current inpatient MAR and their pre-hospitalization home medication list and
contact the prescriber for any new discrepancies noted.
4. The pharmacist will document that medication reconciliation is completed in the
clinical record.
i. Discharges:
1. A physician or designated prescriber generates discharge medication orders
(e.g., the home discharge medication list) for the patient within the discharge
navigator in the clinical record.
2. A pharmacist will reconcile the patient discharge medication orders and
discharge list against the current patient medication list and the patient's home
medication list. She or he will document this verification step by releasing the
discharge medication orders which were generated by the prescriber. The
completion of the reconciliation will also be documented in the clinical record
within the discharge navigator.
3. The pharmacist will review the plan for discharge medications with the patient to
determine if the patient has an adequate medication supply at home, determine
time of estimated departure, review stored medications that the patient brought in
with them at the time of admission, answer any questions and establish the
pharmacy from which the patient wants to receive their medications.
j. For new prescription medications:



UW HEALTH CLINICAL POLICY 4
Policy Title: Medication Reconciliation
Policy Number: 6.1.10

1. If the quantity to be dispensed is not indicated on the discharge medication list
within the discharge navigator completed by the prescriber, a maximum of one-
month supply may be ordered unless otherwise approved by the prescribing
service. The pharmacist will document the amount to be dispensed for all
controlled substances.
2. The pharmacist may call the patient's pharmacy, fax the prescriptions or provide
written discharge prescriptions.
3. The attending physician's name, NPI number, and DEA number are to be
recorded on the each transcribed prescription.
4. All schedule II prescriptions must be signed by a physician with a valid DEA
number.
5. Act 266 of the WI HOPE (Heroin Opiate Prevention Education) Initiative requires
that all practitioners review the Prescription Drug Monitoring Program (PDMP)
before issuing any prescription of a Schedule II-V medication if more than 3 days
for non-hospice patients effective April 1, 2017.
6. The pharmacist must sign his/her name in the 'transcribed by' section of the
prescription blank, since she or he is acting as the physician's designee.
k. If the patient wants the prescriptions sent to the UWHC Outpatient Pharmacy, the
following information shall be provided on the prescription:
1. The patient's medical record and/or account number.
2. The patient's unit, time needed, total number of prescription orders being sent,
allergies and adverse drug reactions, and the pharmacist's pager number.
3. The patient will be provided with a copy of their discharge medication list and
receive discharge medication teaching for each medication, including
written patient information regarding the medication prescribed.
4. The medication list is also forwarded to the provider assuming care for the
patient by the medical records department within 24 hours of discharge.

VI. PROCEDURES FOR NON-INPATIENT LOCATIONS

A. Ambulatory Clinics.
i. A complete and accurate medication history is obtained for each patient and documented in the
clinical record within the appropriate encounter by authorized personnel when a patient checks-in
to a clinic.
ii. The medication list is reviewed and reconciled by the prescriber before any new medications are
administered and/or prescribed.
B. Procedure Areas (including Infusion Center, Cath Lab, Sedation Clinics, and Radiology).
i. A complete and accurate medication history is obtained for each patient and documented in the
clinical record within the appropriate encounter.
ii. For inpatients, the MAR shall be used as the current medication list for reconciliation purposes.
iii. For most outpatients, this can occur through screening reconciliation by documenting the name of
the patient's current medications during the triage or intake process.
iv. The medication list is reviewed and reconciled by the prescriber before any new medications are
administered and/or prescribed.
v. If a new medication is prescribed for the patient to take at home or in a clinic setting (or changes
are made to the current regimen), the patient's electronic medication list is then updated and a copy
of the updated list is provided to the patient and sent to the next known provider of care.
C. Perioperative Areas (including Ambulatory Procedure Center, Outpatient Surgery Center, First Day Surgery,
and Operating Room).
i. A complete and accurate medication history is obtained for each patient and documented in the
clinical record within the appropriate encounter.
ii. For inpatients, the MAR shall be used as the current medication list for reconciliation purposes.
iii. For most outpatients, this will occur through “screening” reconciliation by reviewing and
documenting any changes to the list of patient’s current medications during the triage process, or
upon arrival to the location of the procedure or surgery.
iv. The medication list is reviewed and reconciled by the prescriber before any new medications are
administered and/or prescribed.
v. If a new medication is prescribed for the patient to take at home or in a clinic setting (or changes



UW HEALTH CLINICAL POLICY 5
Policy Title: Medication Reconciliation
Policy Number: 6.1.10

are made to the current regimen) the patient’s electronic medication list is then updated and a copy
of the updated list is provided to the patient and sent to the next known provider of care.
D. Minimal Use Sites of Care.
i. In areas that satisfy all the requirements listed in IV.B. above, screening procedures must be in
place if medications are being administered to ensure the safe administration of medications.
ii. In these areas, managers are responsible for documenting the minimal amount of information to be
collected from a patient prior to administering medications or delivering care.
iii. In these areas, care providers must document that the medication list was reviewed.
iv. See also "Recommendations for Allied Health Professionals Doing Modified Medication
Reconciliation"

VII. EMERGENCY DEPARTMENT

A. A complete and accurate medication history based on the information available at the point of care is
obtained for each patient and documented in the clinical record within the appropriate encounter by an
authorized provider.
B. The patient's list of medications should be obtained as soon as possible during the patient's encounter, after
the management of emergent situations which may prohibit the ability to gather this information upon the
initial contact.
C. The medication list is reviewed by the emergency medicine physician or consulting physician as soon as
possible after arrival before any non-emergent medications are administered and/or prescribed.
D. If a new medication is prescribed (or changes are made to the current regimen), the patient's medication list
is then updated and a copy of the updated list is provided to the patient and the next known provider of care.
E. The list should include all known medications the patient will be taking, updated with changes as prescribed,
and all new medications ordered.
F. This list may include instructions to the patient to contact their primary care provider regarding medication
concerns noted by the emergency department physician.
G. If a patient is admitted to an inpatient unit through the emergency department, the medication history and
reconciliation procedures will be performed by the pharmacist per procedures outlined above for inpatients.

VIII. HOME HEALTH CARE

A. Qualified staff query patients about medication changes, use, new orders, errors, and/or compliance issues
on admission and each home visit thereafter (This includes looking at labels on ordered medication bottles
and discussing dosages and frequency). Qualified staff are also expected to review patient’s use of over the
counter medications and to maintain communication with the patient’s physician about use of over the
counter medications.
B. Patients should be encouraged and assisted with keeping up-to-date lists of their medication orders.
C. Qualified staff teach and assist patients and caregivers in discussing newly prescribed medications with the
ordering physician, to ensure an understanding of why the drug was prescribed and how it should be taken.
D. A complete list of the patient's medications is sent to the next provider when patients are referred or
transferred to another setting, service, practitioner or level of care within or outside the organization. This
includes ED visits (if home care staff are aware when the patient seeks care in an emergency department),
transfer to inpatient hospital, and discharge to other care providers such as clinic, hospice, nursing home,
cardiac rehab, outpatient therapy, or other home health organizations. Home health office staff fax the
medication list when patients are transferred or discharged.
E. Qualified home health staff ensure that the patient is provided with a complete, updated list of medications
upon discharge from the home health agency.

IX. COORDINATION

Author: Pharmacy Manager, Patient Care Services and Regulatory Compliance
Senior Management Sponsor: VP, Professional Services
Approval committees: Medication Safety Committee; Regulatory, Accreditation and External Reporting
Committee; UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: November 21, 2016

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.



UW HEALTH CLINICAL POLICY 6
Policy Title: Medication Reconciliation
Policy Number: 6.1.10

This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

X. APPROVAL

Peter Newcomer, MD
Chief Clinical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

XI. REFERENCES

The Joint Commission National Patient Safety Goals, Available at www.jointcommission.org.
Wisconsin Hospital Association, Checkpoint Error Prevention Measurement Methodology, Version 7.0

XII. REVIEW DETAILS
Version: Revision
Next Revision Due: January 2020
Formerly Known as: Hospital Administrative policy #7.60