This flow diagram highlights the potential gaps and barriers to effective communication about medication orders during discharge prior to redesign of a sound medication reconciliation process.
- Patient being discharged from hospital.
- Physician places discharge order.
- Physician writes new prescriptions, if needed:
- Inconsistent practices for documenting and highlighting changes or updates for patient to home medication list.
- Physician prepares discharge instructions referencing initial medication history within admission note ("history and physical"):
- No standardized, consistent practice for physicians to perform discharge medication reconciliation. Patient safety risks of documenting "resume home meds" not understated. Changes to initial medication history documented to progress notes/addendum may not be captured when preparing discharge notes.
- Nurse counsels patient on discharge instructions and contacts physician if questions or clarifications needed:
- No standardized, consistent process for nurse to ensure patient receiving an updated home medication list. No consistent approach to address and rectify physician documenting "resume home meds."
- Patient discharged.