What You Need To Know
Updated Medication Reconciliation Policy
Hackensack Meridian Health is implementing an updated network wide medication reconciliation policy to provide a consistent, safe and effective process for obtaining, documenting, and communicating medications across a patient’s continuum of care. This will help to ensure we maximize safe medication practices during care transitions.
- A full medication reconciliation is required upon admission (inpatient or observation), change of level of care, discharge to home and/or transfer to a rehabilitation or nursing home facility.
- A focused medication reconciliation is required for “treat and release” patients in the ED and for patients who undergo procedures and return to the patient care unit.
- If the prior to admission (PTA) medication list in the EHR has not been marked as reviewed and complete, the licensed/certified team member MUST verify with the patient, caregiver, or referring facility that this is the most current medication list.
- If admission medications are ordered before the PTA medication list is marked as reviewed and complete during the current encounter, it may not be accurate and could be missing or contain incorrect medications.
Key Teaching Points for Admission Med Rec
- The PTA med list auto populates (pulls prescriptions from previous admissions/outpatient pharmacies) and does NOT guarantee completeness or accuracy.
- Another team member (e.g. nurse, pharmacist) may have already worked on the PTA Med List, but the Attending of Record/Licensed Practitioner is ultimately responsible for ensuring that the PTA list has been marked as reviewed and complete.
- Marking status as complete indicates list is ready to be reconciled for admission orders. An incomplete list (in progress, waiting, unable to assess) indicates further clarification is necessary prior to reconciliation.
- A complete and accurate admission med rec will allow for a smoother in-hospital and discharge med rec process.
Step by Step Instructions for admission medication reconciliation (with pictures)