Medication Reconciliation and Drug Regimen Review (Home Health)

Inspection template for home health clinicians to reconcile the patient’s medication list and perform the OASIS drug regimen review (DRR) to identify discrepancies, potential adverse effects, interactions, duplicate therapy, and other medication-related risks during transitions of care.

Review Context and Medication Sources

• Review type and timing documented
  Record the context for the medication review.
• Current medication sources reviewed
  Identify all sources used to build the best possible medication list.
• Medication list is complete and current
  All active prescription, OTC, supplement, inhaled, topical, and PRN medications are captured.
• High-risk medication changes since last review identified
  Recent starts, stops, dose changes, or frequency changes that may affect safety were identified and documented.

Medication List Reconciliation

• Prescription medications match current orders
  Each prescription medication name, dose, route, and frequency matches the most current order or discharge instruction.
• Over-the-counter medications and supplements reviewed
  OTC products, vitamins, herbal products, and nutritional supplements are included in the reconciliation.
• PRN medications have clear indications and limits
  As-needed medications include a documented indication, maximum daily dose, and safe use instructions when applicable.
• Duplicate therapy identified and addressed
  Potential duplicate therapy within the same class or with overlapping ingredients was checked and resolved or escalated.
• Medication omissions or unintended discontinuations identified
  Any missing medications, unintended gaps, or stopped therapies were identified and communicated for follow-up.

Drug Regimen Review: Safety and Interaction Screening

• Potential drug-drug interactions reviewed
  The regimen was screened for clinically significant interactions, including additive sedation, bleeding risk, QT prolongation, and CNS depression where relevant.
• Potential drug-disease interactions reviewed
  The regimen was screened for conditions such as renal impairment, hepatic impairment, diabetes, heart failure, COPD, falls risk, or anticoagulation risk when applicable.
• Adverse effects or toxicity signs assessed
  Symptoms, vitals, or observations suggestive of adverse drug effects were assessed and documented.
• Medication allergies and intolerances verified
  Allergies, adverse reactions, and intolerances were reviewed against the current regimen.
• Polypharmacy risk reviewed
  The regimen was reviewed for medication burden, high-risk combinations, and opportunities to simplify therapy or reduce risk.

Adherence, Administration, and Patient Understanding

• Patient/caregiver can describe how medications are taken
  The patient or caregiver can explain dose, route, timing, and purpose for key medications as appropriate.
• Adherence barriers identified
  Identify barriers that may affect safe adherence.
• Medication administration technique observed or confirmed
  Technique for inhalers, injections, eye drops, insulin, anticoagulants, or other special forms was observed or confirmed when applicable.
• Medication organization supports safe use
  Pillbox, blister packs, labels, schedules, or other supports are adequate for the patient’s regimen and abilities.

Communication, Escalation, and Follow-Up

• Discrepancies communicated to prescriber or pharmacist
  Medication discrepancies, safety concerns, or unresolved questions were communicated to the appropriate licensed provider.
• Follow-up plan documented
  A plan exists for clarifying orders, obtaining missing medications, monitoring adverse effects, or rechecking the regimen.
• Patient/caregiver education provided
  Education was provided on medication purpose, schedule, side effects, red flags, and when to seek help.
• Urgent medication issue escalated immediately
  Any critical issue such as severe reaction, overdose risk, contraindicated combination, or missing life-sustaining medication was escalated without delay.

Documentation and Sign-Off

• Medication reconciliation documentation is complete
  The chart includes the reconciled medication list, discrepancies, actions taken, and any unresolved items.
• OASIS DRR findings documented in the record
  Drug regimen review findings are documented clearly enough to support OASIS Section N and clinical follow-up.
• Inspector signature
  Signature of the clinician completing the review.