Standard Operating Procedures safety compliance

Medication Reconciliation

JC NPSG 03.06.01 med reconciliation at admission / transfer / discharge.

Built for: Healthcare Hospitals Ambulatory

What's inside this template

Obtain BPMH (best possible medication history)
Interview patient and/or caregiver, review pharmacy refill history, check Surescripts. Capture: drug name, dose, route, frequency, last dose taken.
Compare to ordered meds
Side-by-side compare BPMH to currently ordered meds. Flag discrepancies: omissions, duplications, wrong dose, wrong frequency.
Reconcile with provider
For each discrepancy, get provider intent. Continue / hold / discontinue with clear rationale.
Update record + educate
Update EHR. Provide reconciled med list to patient at discharge or transfer; review verbally; teach-back on any new med.

Admission med rec

Discharge med rec

Inter-facility transfer

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Type: safety Category: Safety Compliance Difficulty: Intermediate Time: 20 min RN Pharmacist Provider Hospital Ambulatory Clinic

Obtain BPMH (best possible medication history) verification
10 min

Incomplete BPMH at admission is the #1 source of med rec errors. Spend the time.

Interview patient and/or caregiver, review pharmacy refill history, check Surescripts. Capture: drug name, dose, route, frequency, last dose taken.
Compare to ordered meds verification
5 min

Side-by-side compare BPMH to currently ordered meds. Flag discrepancies: omissions, duplications, wrong dose, wrong frequency.
Reconcile with provider decision
3 min

For each discrepancy, get provider intent. Continue / hold / discontinue with clear rationale.
4

Update record + educate
2 min

Update EHR. Provide reconciled med list to patient at discharge or transfer; review verbally; teach-back on any new med.

Outcome: Reconciled list documented and shared with patient + receiving provider.