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HOME > FPP POLICIES > Medication Reconciliation Policy

 Medication Reconciliation Policy

 

Printable Version of Policy

Approved by FPP Clinical Practice Committee:  May 17, 2011

  

PURPOSE:

The purpose of this policy is to confirm Washington University’s commitment to conducting business in compliance with all applicable laws, regulations and University Policies.    This policy outlines the consistent discrete data capture in the Ambulatory Electronic Medical Record.  The discrete data captured provides critical data to other clinicians, supports the sharing of critical health information through clinical document exchange, research, and facilitates automated checking and alerts by the system. 

The final outcome of the medication capture and reconciliation is to generate the most accurate medication list available for clinical alerts, to reduce the risk of adverse medication events and to notify Washington University Physicians of potential issues related to medication non-compliance.

  

POLICY:

Documentation 

1.   The provider or clinical staff per protocol in the ambulatory setting will review and document the patients’ list of current medications (including prescription, over-the-counter, herbals, and nutritional supplements) including drug name, dosage, frequency and route in the Allscripts Medication section during each transition of care visit and/or annually, whichever comes first.

2.   During the prescribing process, and when applicable, it is recommended that the Prescription Status field in Allscripts be changed to ‘Complete’ and the known completion date be entered.  On the completion date, the system will move the medication from the ‘Active’ to the ‘Completed’ medication list.

3.   The absence of a valid entry in the medication list indicates that we have not asked the patient if they are taking any medications. 

4.   If the patient has indicated that they are not currently taking any medications, the clinical staff will enter “No Reported Medications” in the Allscripts Medication section

5.   Medications prescribed by other physicians or entities will be entered in the Medication History section. 

 

Reconciliation

1.   The medication history may be obtained from the patient, family members who are present during the visit, and/or information from the hospital or transferring/referring physician.  This information may also be available in ClinDesk, Eclipsys or other hospital systems.

2.   Active medications prescribed outside of Washington University that the patient reports are discontinued will be discontinued in Allscripts using the ‘Record D/C’ function with the appropriate Change Status Reason selected from the menu.

3.   Active medications prescribed within Washington University that the patient reports are discontinued will ONLY be discontinued by the prescribing department/division using the Allscripts Order D/C function with the appropriate Change Status Reason selected from the menu.

4.   Active medications prescribed within Washington University but outside of your department/division that the patient reports are discontinued will have an annotation added, referencing the patient’s comments/reasons for discontinuing the medication and any other relevant information.  The patient should be instructed to speak to the prescribing provider about discontinuation.  An electronic “Task” can also be sent to the prescribing provider if they believe the patient’s discontinuation of the medication will have an adverse impact on the patient’s health. 

5.   In order to maintain an accurate and complete medication history, medications that are renewed will be renewed using the Allscripts ‘Renew with Changes’ function. Unless clinically relevant, a duplicate medication should not be entered.

6.   Once the patients’ medication list has been reviewed and documented in Allscripts, the list should be marked as ‘List Reconciled’.  The user name, section, and date are automatically stored in the reconciliation history.

 

Medication Reconciliation Protocol

Per this protocol, I authorize the Nursing/Medical Assistant staff in my outpatient clinic setting to reconcile my patients’ medication lists.  They should review and document the patients’ current medications (including prescription, over-the-counter, herbals, and nutritional supplements) including drug name, dosage, frequency and route in the Allscripts Medication Section as outlined in the Washington University School of Medicine Medication Reconciliation Policy.   

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    Washington University Physicians