Figure 4: Medication Reconciliation Upon Discharge: High Level Process

Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation

Figure 4: Medication Reconciliation Upon Discharge: High Level Process Map After Redesign (Text Description)

The flowchart begins with Patient discharged from Hospital. Directly below this, in the center of the chart is:
Med Profile ("One Source of Truth")

Medication(s) Being Given (inpatient)
with space to record current and past medications.

Following that is:

Prescription(s)/Home Medications (outpatient)
with space to record current and past prescriptions.

Flowing into the Med Profile is:

• Physician places medication reconciliation order and reviews hospital orders and pre-admission medication list.
• Physician updates prescription/home medications to reflect new discharge medication list.
• Nurse completes nursing discharge note and is prompted to confirm patient is being discharged with an updated home medication list from the physician.
• Patient is counseled.
• Physician is consulted for resolution of discrepancies and questions.

Flowing out of the Med Profile is:

• Physician pulls updated home medication list into discharge instructions (for patient) and discharge summary (for next provider of care), highlighting changes.

Additional information:

Med Profile:

• Single location for documenting and confirming home medications, share by all disciplines.
• "One Source of Truth" for review and reconciliation of inpatient and outpatient medications.
• Changes and updates to home medications clearly accessible.
• Prescription/home medication information remains stored in the current folder and is available for review and modifications for future admissions.

Forms:

• Standardizes physician review and documentation of home medications in preparation for discharge.
• Template provides reminders and section for physician to highlight changes to prior medications and document new prescription information.
• Creates standardized process for nurses to identify, resolve, and document followup on unintended discrepancies at discharge.

Sequence of Tasks:

• Physician places medication reconciliation order, performs reconciliation, and updates home medication list in preparation for discharge.
• Nurse prompted to confirm history patient receives an updated medication list upon completion of nursing discharge form.

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