What Is A Medication reconciliation Form
There are several points along a patient’s path through the healthcare system where medications can be missed, transcribed incorrectly, or otherwise documented in error. For patients who have had transitions of care, e.g. changing providers, locations, or practitioners, this reconciliation process is particularly important. Having an accurate list of current medications is one of the most integral parts of a patient’s medical history, and when there are discrepancies in what medications the patient is currently taking, or which they should continue with, the risk of making a poor treatment decision greatly increases.
Our is designed to ensure any discrepancies in a patient’s medication regime are resolved, and an accurate and complete list of current medications can be reconciled from the information gathered. This is a two-step process, with the first being gathering the best possible medical history (BPMH) of the patient, including as much information on all medications the patient has been prescribed previously as possible. The second step is resolving any discrepancies identified, for example, if two medications have been prescribed for the same condition, or if two different dosages are documented. For each discrepancy, a decision must be made as to how this discrepancy will be solved. Once all discrepancies are resolved, you can proceed to the final reconciled medication table.
How To Use This Template For Medication Reconciliation Forms
Achieving the best possible medication reconciliation for your patient is a careful and involved process, and while this form is designed to help you work methodically, it is a good idea to understand how exactly to proceed using this form.
Step One: Patient Information
The first thing you have to do is fill in your patient’s information. This section includes information on their allergies, medication management, and their community pharmacy contact details. As conducting a medication reconciliation is a team effort between physicians, nurses, pharmacists, the patient, and their family/caregivers; having these contact details will be very handy.
Step Two: Best Possible Medication History (BPMH)
Now we can begin the information-gathering stage. If you cannot trust the EHR to be comprehensive, i.e. they are a new patient to your hospital, then use whatever resources you have to obtain information on your patient’s medication history, including interviewing your patient and their family, through previous discharge letters or medication orders, requesting pharmacy records, looking at labels on the patient’s medication bottles or boxes, or however else you can obtain this information. As you go, note down the sources you used to obtain this information so someone in the future can trace the sources for this medication reconciliation. As you encounter a new medication, fill it in on the BPMH table, and for any discrepancies, you come across (wrong medication, wrong dosage, incorrect or incomplete prescription etc.) check the discrepancy box.
Step Three: Evaluate Discrepancies in BPMH and Set Actions
Once you’ve obtained the BPMH, it’s time to work through all the discrepancies you found. Within your multidisciplinary team, decide on a resolution plan for each medication. For all medications in the BPMH, conduct a review of the action your patient is to take; “Start” for a new medication to be added to the medication regime, “Continue” for a medication that is to remain unchanged, and “Stop” for any medications the patient is to cease taking.
Step Four: Reconciled Medication List
Take all the medications from the BPMH with actions “Continue” or “Stop” and copy them into the reconciled medication list on the second page of this form. This is your patient’s new medication regime, with all discrepancies resolved and including any new medications.
Step Five: Sign, Date, Store Securely
Ensure for each table that the person completing signs and dates this document to authorize the medication reconciliation form, and to improve accountability within the reconciliation process. If you have worked as part of a team, including the name of the members of your multidisciplinary team here. Lastly, store the reconciliation form securely.
Medication Reconciliation Form Example (Sample)
Want some more clarity on how this template works? Not a problem, we’ve provided an example medication reconciliation form using this template to give you a better idea of how to complete this form in your own practice. This template illustrates the differences between which medications are included in the BPMH table vs. the reconciled medication list, and how to use the various features of this interactive PDF template. Take a read of the example medication reconciliation form here.
Who Can Use this Printable Medication Reconciliation Form (PDF)?
This medication reconciliation form was designed with all different medical practitioners in mind. The medication reconciliation process is a team process, with input from the patient, their family and caregivers, pharmacists, nurses, and physicians. As such, this form may be used by:
- Nurses and nurse practitioners
- Physicians and resident physicians
- Pharmacists, pharmacy technicians, and trainees
- Midwife practitioners
- Specialty physicians such as psychiatrists.
It is important to note that while the form will be completed by one or more of these professionals working in a team, it is likely that the information gathered will come from all different sources including the patient, their family, and any of their previous medication prescribers.
Why Is This Form Useful For Medical Practitioners
Dedicated Action Section
When working within a team to solve complex problems, it can be easy for loose ends to go untied. To prevent this, we have included a dedicated column for selecting your chosen action. This ensures you have a plan for your patient, and no grey areas remain regarding their medication regime once the reconciliation process is complete.
Highlight discrepancies and resolutions
One of the important decisions you and your team will make as part of the reconciliation process is how to resolve any discrepancies you come across. What will you do if a medication has a dosage that seems incorrect? Or if your patient has been prescribed two medications for the same condition by two different physicians? Your team will rely on your clinical judgment to make these important decisions, and our form can help you highlight the discrepancies you need to address with our discrepancy checkbox column.
Why Use Carepatron For Medication Reconciliation Form?
Your medical reconciliation forms are important medical records that will include sensitive patient information with a legal requirement to be stored securely. As such, having one reliable, secure place to store your sensitive records is a big help in meeting your legal obligations.
Carepatron is a fantastically integrated software solution that offers a digitally encrypted, HIPAA-compliant method to store your medical reconciliation forms, along with all the other documents making up your patient’s medical record.
Keeping your patient’s medical records in Carepatron has huge advantages for security, as well as accessibility- so your colleagues will be able to access your medication reconciliation form anywhere they need from Carepatron’s mobile or desktop platform. Additionally, empower your patients to take responsibility for their medical treatment and share your patient’s medical records through Carepatron’s dedicated patient portal. Your patients will also be glad for the helpful, automated SMS or email reminders you can send out using Carepatron, and you’ll enjoy the reduction in no-shows to appointments with you and the spare time you’ll have from optimizing your calendar.
Manage billing and coding, sync your teams’ calendars, and access this template, and many others, right from within Carepatron.