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

Table 3: Critical Thinking Process to Identify and Clarify Discrepancies

Category Definition Example Requires Physician Followup?
&One-to-One" Match Medications ordered for the patient during the episode of care or upon discharge match what the patient was taking prior to admission.
  • Patient takes furosemide 40 mg by mouth twice daily at home, which is ordered upon admission.
  • Patient's pre-admission dose of simvastatin 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 (e.g., based on information gathered on rounds, based on a review of the physician's history and physical 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 were changed due to hypotensive episodes.
  • Warfarin and aspirin held for a procedure.
  • Formulary substitution.
Unintended Discrepancy Discrepancies exist and require clarification of intent because there is no supporting documentation of 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.
Page last reviewed August 2012
Page originally created August 2012
Internet Citation: Table 3: Critical Thinking Process to Identify and Clarify Discrepancies. Content last reviewed August 2012. Agency for Healthcare Research and Quality, Rockville, MD.