Medication reconciliation is the process of comparing a patient's medication list to a physician's orders to minimize errors. It occurs at admission, transfer, discharge, and after surgery. Nurses document the patient's home medications and ED medications. Physicians then reconcile all current and home medications within 24 hours, noting any changes. Discharge reconciliation reviews chronic, new, and active medications to prevent duplication or interactions and provide a complete list for continued care.

1. Medication Reconciliation
Medication Reconciliation is the process of comparing a patient’s
best-known list of current medications against the physician’s
admission, transfer, and/or discharge orders
 This process serves to minimize medication errors, including
omissions, duplications, or drug interactions.
 Sources for obtaining the most accurate medication list possible
when the patient and/or family are not considered to be a reliable
source of information include:
• Transferring or discharging facility
• Primary care physician office record
• Previous hospital records
• Patient’s pharmacy

2. Medication Reconciliation: Admission
 The ED nurse documents the patient’s current medications in
the ED electronic health record. The list includes medication
name, dosage/strength, route, and date/time of last dose
 The emergency department medication list may be used by
the admitting nurse as a baseline to verify the accuracy of the
patient’s home medications a second time. However, the ED
list shouldn’t be used without other verification.
 A list of the patient’s home medications is documented in
CPSI via the Medication Reconciliation: Home Med List
eform. It includes the medication
name, dosage/strength, route, and date/time of last dose.
This list is printed and placed under the H&P tab on the chart.
This is done for outpatients, observation patients, and
inpatients

3. Medication Reconciliation: Admission (cont)
 The Medication Reconciliation: Admit Orders eform is
printed and placed under the physician’s orders section of
the chart
 Lock this eform before printing because this is an actual
physician order sheet. Every effort will be made to keep
the form on top of the most current order sheet until
addressed by the physician
 The physician reviews the home med list with any
medications ordered since arriving to WCMC, and checks
the box to either continue or discontinuing each home
medication

4. Medication Reconciliation: Admission (cont)
 All inpatients will have medications reconciled by the physician
within 24 hours of admission.
• However, if there are medications where missing or delaying a
dose might present a higher risk to the patient, the nurse can
notify the physician and obtain a telephone/verbal order for
completing the admission Medication Reconciliation process .
 If the list of the patient’s home medications needs to be amended
after the initial medication reconciliation, the correct information
should be entered on the Home Medication List eform, and the
doctor notified of the corrected information.
 If the doctor wants the corrected home medication to be given to
the patient, an order is written for the new or changed medication.

5. Medication Reconciliation: Admission (cont)
These medications are brought to the attention of the physician for a
medication order prior to the next scheduled dose and include the
following medication categories:
 Antibiotics  Inhalers
 Insulin  Antiseizure medications
 Oral hypoglycemics  Ophthalmic medications
 Antihypertensives  Pain medications
 Antiarrhythmics  Antianginal medications
 Anti-rejection medications
Home medications that require administration to the patient prior to
reconciliation by the physician are written on a separate order sheet as a
verbal or telephone order
The home medications are updated with any new information throughout
the hospital stay even if the admission medication reconciliation has been
completed by the physician

6. Medication Reconciliation: Post-Operative
Before the patient goes to surgery, nursing services prints the
Physician Order Report (for medications) and places in the physician
order section of the chart
The surgeon verifies additions or deletions to be made to the
patient’s current medications by checking the appropriate box on the
report to either continue or discontinue each medication listed and
signing/dating the report
OR personnel will stamp “Post-Op” on the Physician Order Report.
The Physician Order Report is faxed to the pharmacy as a physician
order

7. Medication Reconciliation: Discharge
Medication reconciliation upon discharge is performed with
special attention devoted to:
•Medications required for the patient’s pre-admission
chronic ailments
•Medications for newly diagnosed clinical conditions
•Prevention of therapeutic duplication/drug interactions
For inpatients, the Physician Order Report (for medications) is
printed from CPSI by nursing services and placed in the physician
order section of the chart for the physician to review prior to
patient discharge. (NOTE: This report is a list of all active
medications and will not list any home medications that weren’t
continued during the hospital stay)

8. Medication Reconciliation: Discharge (cont)
The physician will review the Physician Order Report for decision
to either continue or discontinue all medications listed on the
report by checking the appropriate box on the form and
signing/dating the form
 The physician will also review the Home Medication List under the
History and Physical tab on the chart in order to reconcile any home
medications that may have changed or that were not continued
during the hospital stay
NOTE: These medications will not be displayed on the Physician
Order Report
Any prescriptions are written on the Physician’s Order sheet with
the rest of the discharge orders

9. Medication Reconciliation: Discharge (cont)
At Discharge;
The Physician Order Report serves as the physician’s
discharge medication orders
 OR the physician may choose to write out the reconciled list
of medications the patient is to continue after discharge
NOTE: It is not an acceptable policy for the physician to
use the 24 hour summary to check which medications he
wants continued after discharge. This page is not a
complete list of all medications, and the 24 hour summary
is not considered a part of the permanent record

10. Medication Reconciliation: Discharge (cont)
Nursing must verify that all home medications and active
medications are addressed by the physician in order to provide
the patient with a complete reconciled discharge medication
list
Nursing must notify the physician of any medications (home
or active) that he did NOT order to be continued or
discontinued after discharge
After all medications are reconciled, the nurse provides a list
of discharge medications on the Discharge Instructions Eform
The patient is instructed to take the Discharge Instructions
and Medications List as well as their medication bottles to their
next appointment with their physician or caregiver