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Critical Thinking—Clarifying Discrepancies Identified During Reconciliation*
||REQUIRES PHYSICIAN FOLLOW-UP? (Yes/No)
||Medications ordered for patient during episode of care or upon discharge match what patient was taking prior to admission (entry) to the organization
||Patient takes furosemide 40 mg by mouth twice daily at home; ordered upon admission.
Patient's pre-admission dose of simvastatin 40 mg by mouth every evening is continued during the hospital stay and at discharge.
|Intended Discrepancy (i.e., purposeful)
||Discrepancies exist but are appropriate based on the patient's plan of care—i.e., information gathered during rounds, based on a review of the physician's history and physical ("H&P") and progress notes, based on communication/handoffs in preparation for discharge, etc.
||Antibiotics started for infection
"As needed" medications ordered for pain/fever
Pre-admission doses of patient's blood pressure medications changed due to hypotensive episodes
Warfarin and aspirin held for a procedure
||Discrepancies exist and require clarification of intent because there is no supporting documentation or explanation based on the patient's current clinical condition or care plan.
||The patient takes her blood pressure medication twice daily at home but it's ordered only once daily in the hospital. No indication for frequency change and patient's current blood pressure slightly elevated.
Patient's simvastatin was omitted from their discharge instructions without any clear indication for why.
|Yes- Physician should be consulted for resolution and resulting changes and/or clarifications documented.
*Adapted from Gleason et al. Am J Health-Syst Pharm. 2004; 61:1689-95.
Adapted from Gleason et al. Reconciliation of discrepancies in medication histories and admission orders of newly hospitalized patients. Am J Health-Syst Pharm
. 2004; 61:1689-95.
The overall goal of medication reconciliation during transitions or handoffs in care is to ensure that any changes made to the patient's current medications, such as omissions, dose changes and/ or deletions, are intentional based on the patient's current clinical status and desired care plan. Below is a table to help disciplines performing reconciliation walk through the "critical thinking process" for identifying discrepancies and determining if clarifications are required. It is important for physicians to provide clear documentation and communication regarding medication ordering decisions and care plans to help minimize unnecessary pages or calls. In addition, patients should receive an updated, complete list of their medications and receive education on any changes to their medication regimen to ensure understanding in preparation for discharge.
The overall goal of medication reconciliation is to ensure that any changes made to the patient's current medications, such as omissions, dose changes and or deletions, are intentional based on the patient's current clinical status and desired care plan. Discrepancies identified that are inconsistent with documented care plans and/or are not explained by the patient's current clinical status (i.e., unintended discrepancies) should be discussed with the physician for resolution, and resulting changes and/or clarifications should be documented. Patients should be educated on any changes to their medication regimen to ensure understanding in preparation for discharge.
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