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Run: Medication Reconciliation

Medication Reconciliation SOP template for admission, transfer, and discharge. Use it to compare home medications with current orders, resolve discrepancies,...

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Steps

The admitting, transferring, or discharging clinician verifies that medication reconciliation is required for the current transition of care. Record the transition type in the EHR before proceeding.
The nurse or pharmacist obtains the patient’s home medication list from the patient, caregiver, outpatient pharmacy, prior records, or other approved sources. Include prescription medications, over-the-counter products, vitamins, supplements, and as-needed medications when available.
The pharmacist or authorized clinician compares the home medication history against the current ordered medications. Review each medication for omission, duplication, dose difference, route difference, frequency difference, formulation difference, and therapeutic duplication.
The clinician contacts the responsible prescriber for each unexplained discrepancy and confirms whether the medication should be continued, modified, held, or discontinued. Document the rationale for each decision in the EHR.
The clinician updates the active medication list to match the final reconciled orders. Remove discontinued medications, add newly ordered medications, and correct dose, route, and frequency details as needed.
The discharging or transferring clinician provides the reconciled medication list to the receiving care team and the patient or caregiver, including start, stop, and changed medications. Confirm understanding using the organization’s teach-back process when required.
The clinician documents completion of medication reconciliation in the EHR. If any medication history cannot be verified, or if a high-risk discrepancy remains unresolved, escalate to the pharmacist, attending provider, or unit supervisor according to facility policy.

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