Medication Reconciliation Report Guidelines

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					                        Medication Reconciliation Report Guidelines

Medication reconciliation is a process employed to improve medication safety across the
continuum of care.

When a patient is admitted to the hospital a medication history is completed by the admitting
nurse. This medication history will appear on a medication reconciliation report which is used to
compare home medications with inpatient medication. A MRR report will print each morning to
be used for that day. The clinical team will review patients prior to morning rounds. The
following guidelines should be used in the medication reconciliation process:

   a) Check patient's home medication list for errors

           a.   incorrect drug names

           b. incorrect doses

           c. incorrect directions

           d. duplications of therapy ( brand and generic names, 2 drugs from the same class)

           e. the patient H&P may be used as a reference if the home medication list does not
              make sense or seems questionable

   b) Match patient’s home medication list with current inpatient orders

           a. If no meds are ordered patient may be NPO for a procedure

           b. Check labs for drug levels as something may be held from toxicity

           c. Consider formulary substitutions as continued home medications

           d. Keep in mind there may be more medications ordered for inpatient stay

           e. If a patient is on oral hypoglycemics as an outpatient, inpatient insulin may be an
              appropriate substitute

           f. The patient H&P may be used as a reference if the home medication list does not
              make sense or seems questionable, also refer to consults and progress notes as
              needed to gather sufficient information on the patient.

   c) Collect and write down patient’s pertinent lab values on the MRR that will aid
      medication monitoring (note SrCr, BUN, Ht and Wt will print automatically on the
   d) Refer to the admission diagnosis on the MRR. You may need to reference the H&P for
      complete medical history. Diagnoses should match the patient’s current medication
         a. Look for medications with no indication for use
         b. Look for conditions that are not being treated (patient may have declined
              treatment of not tolerated treatment in the past.. this needs to be considered).

   e) Make sure that the patient is receiving a safe and effective dose of medication.

Mark the appropriate intervention code from the list below on the original copy of the MRR
report for the technician to use in entering the information into our database.
        1. MRR- ADR detected
        2. MRR-Diagnosis with no treatment
        3. MRR- Home medication not re-ordered
        4. MRR- Inappropriate medications identified
        5. MRR-Incomplete history
        6. MRR-Medication error detected
        7. MRR-Medication ordered without indication
        8. MRR- Missing dose / frequency
        9. MRR- Reconciliation problem >72 hours
        10. MRR Reconciliation problem 24 hours after initial
        11. MRR Reconciliation problem 48 hours after initial
        12. MRR Reconciliation problem Initial
        13. MRR-Risk analysis performed

Highlight any potential problems with the medication profile on the MRR report. If any of the
problems from the above list (numbers 1-8) are identified, make a copy of the MRR report and
give it to the nurse in charge of that patient while on morning rounds. Explain to the nurse what
information is missing or needs correction.

       Note: For interventions 9-13, tally the total number on a daily basis and give this along
       with the reports to the technician for entry in the database.

All other findings should be discussed with the clinical pharmacist(s) on duty for appropriate
follow-up and intervention.

All reports are to be kept in the MRR folder under the day of the week in which they were
reviewed. Each morning, refer to the previous days reports for notes and follow up as well as
completing the review process on new patients.

The ultimate goal of the process is to discharge the patient with a complete and accurate list of
medication that they are supposed to be using.