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Pharmacist Discharge Reconciliation and Order Modification (3.1)

Pharmacist Discharge Reconciliation and Order Modification (3.1) - Policies, Clinical, UWHC Clinical, Department Specific, Pharmacy, Decentral

3.1

POLICY & PROCEDURE





Effective Date:

September 2013
 Pharmacy Policy Manual
Chapter: Administration
Operations Procedure Manual
Chapter:

Policy #: 3.1

Original
 Revision 07/17

Page 1
of 3

Title: Pharmacist Discharge
Reconciliation and Order
Modification


I. PURPOSE: This policy defines for pharmacists, at the time of discharge, the medication
reconciliation procedures for allowing appropriate quantities of medication to meet the intended
course of therapy, refills until the patient can establish and/or re-establish care with an outpatient
prescriber, apply inpatient therapeutic interchange protocols to interchange discharge prescriptions to
meet the patient’s outpatient insurance coverage, renal function, and drug formulation needs.

II. POLICY: Pharmacy staff shall follow the procedure outlined within the Pharmacist Discharge
Reconciliation Policy when reviewing all medication orders at the time of discharge. Patient
“discharge” includes patients discharging from the inpatient facility or the emergency department.
Adjustment of medication quantity for CII medications is not delegated to pharmacists and requires a
provider order.

III. PROCEDURE

A. Provider Discharge Reconciliation
1. Providers complete discharge medication reconciliation in Health Link and prescribe
medications to be continued at discharge
2. If a specific quantity and/or number of refills is desired, that information is entered into
the discharge order and in the free-text field of the medication order the statement “Do
not adjust quantity or refills” or similar statement is included.
3. If no refills or quantity is specified or if the statement “Do not adjust quantity or refills”
does not appear, the quantity and refill decision is delegated to the discharging inpatient
clinical pharmacist per Delegation Protocol 74.
4. If the inpatient order that is continued at discharge had a “do not modify per protocol”
statement on the order the therapeutic interchange, extended-release interchange, route
interchange and renal dosing protocol delegation does not apply at discharge.
5. If no “do not modify per protocol” statement exists, these protocols apply to discharge
prescription orders either to reverse the outpatient to inpatient conversion or to
interchange between products based upon the patient’s dosage form needs or the
patient’s outpatient insurance formulary.
B. Discharging Clinical Pharmacist
1. Assessment
a. Time to first follow-up appointment with a prescriber who will manage the
discharge medications, if they are for long-term use
b. Duration of therapy documented in inpatient notes or discharge order
c. Duration of therapy received while an inpatient as documented in the
medication administration record
d. Number of administrations per day of as needed medications

POLICY & PROCEDURE





Effective Date:

September 2013
 Pharmacy Policy Manual
Chapter: Administration
Operations Procedure Manual
Chapter:

Policy #: 3.1

Original
 Revision 07/17

Page 2
of 3

Title: Pharmacist Discharge
Reconciliation and Order
Modification

e. Prescription drug coverage, formulary and co-pay, if applicable
2. Quantity and Refill Adjustment
a. If a quantity and refills exceeding the expected follow-up date is provided by
the prescriber no action is necessary
b. If the next appointment for follow up is not known and no quantity or refills
are specified by the prescriber, a maximum of a 30 day supply should be
provided to the patient
c. For “new” medications at the time of discharge
i. For scheduled medications, the pharmacist may adjust
the prescribed quantity and/or refills, in monthly
increments, to ensure the patient has enough prescribed
medications until seen in follow up. Maximum of a 60
day supply.
ii. For as needed or “PRN” medications, assess and
validate the quantity and/or refills prescribed. Contact
provider for adjustments to quantity.
d. For “prior to admission medications” where “refills” are needed at the time of
discharge
i. For scheduled medications, the pharmacist may adjust
the prescribed quantity and/or refills, in monthly
increments, to ensure the patient has enough prescribed
medication until seen in follow up. Maximum of a 60
day supply.
ii. For PRN medications, assess and validate the quantity
and/ore refills prescribed with the patient, and provide a
maximum prescription quantity for a 60 day supply.
e. The prescriptions are adjusted to the required quantity and refills in Health
Link and signed using “Per protocol, no cosign needed”
3. Interchange Protocol Application
a. Discharge prescriptions for medications covered by the renal dosing protocol
will be adjusted according to the “Renal Function-Based Dose Adjustments
Adult Inpatient Clinical Practice Guideline”
b. Discharge prescriptions for non-extended release medications that were
interchanged on admission can be reversed to their original formulation
according to the “Extended-Release Medication Interchange Protocol”
c. Discharge prescriptions for medications covered in the route interchange
protocol will be adjusted according to the “UWHC Guideline for Parenteral
and Enteral Route Interchange in Adult Patients”.

POLICY & PROCEDURE





Effective Date:

September 2013
 Pharmacy Policy Manual
Chapter: Administration
Operations Procedure Manual
Chapter:

Policy #: 3.1

Original
 Revision 07/17

Page 3
of 3

Title: Pharmacist Discharge
Reconciliation and Order
Modification

d. Discharge prescriptions for medications covered by the “UWHC Therapeutic
Interchange Protocol” and contained on P&T approved guidelines will be
interchanged to meet the formulary requirements of a patient’s outpatient drug
coverage or their previously prescribed therapy.

V. References and Related Policies, Procedures
A. Orders Management Protocol, Delegation Protocol #74
B. Hospital Administrative Policy Medication Reconciliation 7.60
C. Gray T, Bertch K, Galt K, et al. Guidelines for therapeutic interchange-2004.
Pharmacotherapy. 2005;25:1666-1680.
D. Pharmacy Policy 11.8 Procedure for Establishing a Therapeutic Interchange.
E. Fox E, Beckwith C, Tyler L. Pharmacy-administered IV to oral therapeutic interchange
program: development, implementation and cost-assessment. Hosp Formul. 2003;38:444-
452.
F. Renal Function-Based Dose Adjustments Adult Inpatient Clinical Practice Guideline
G. Extended-Release Medication Interchange Protocol
H. UWHC Guideline for Parenteral and Enteral Route Interchange in Adult Patients
VI. Coordination
A. Authored by: Michelle Thoma, PharmD, BCACP
B. Reviewed by: David Hager, PharmD, BCPS
C. Committee Approval: Pharmacy Performance Improvement and Regulatory Compliance
(PPIRC) Committee




Approved By:___________________________
Director of Pharmacy Services

Date:_________________