Discharge Medication Reconciliation

Prerequisite

Complete the Medication Reconciliation Configuration.

Discharge Med Reconciliation tab

Similar to Admission Med Reconciliation, the Discharge Med Reconciliation tab is divided into three main sections. 

• Section 1 is a list of all the inpatient medication orders that are currently active for the patient. Last dose information is available.  
• Section 2 is called the Home Medications Scratchpad. Any active orders, reported or prescription, will populate here. Assuming the medication history is documented appropriately on admission, this list will rarely be blank. Discharge reconciliation will allow the provider to manage this list by adding from the inpatient medication list, discontinuing active home medications, or adding new ones.
•  Section 3 is the order details pane. New discharge prescriptions can be placed here as well as allowing users to edit details for any orders on the Home medications scratchpad.  

Note: Medication reconciliation has been designed to manage one external medication list for the client (also viewable in the Home Medications tab). This list is used to determine what medications should be continued on admission, and this list is updated during discharge medication reconciliation to communicate changes to the client or patient upon discharge.

Navigate the Discharge Med Reconciliation tab

Users will review the Inpatient Medications list and determine which orders should be added to the discharge medication list. Prior to loading the medication information, the system will check to determine if a match is available for each order in the Inpatient Medications section. In the instance where the action column is prepopulated with a NO MATCH indicator, this means the system was not able to safely identify a best match for the system. Those orders cannot be added to the scratchpad. Instead, these orders will need to be held and the provider will determine an appropriate alternative.  

The user can select one or more orders to add to the scratchpad. Users can highlight multiple rows to be added by pressing and holding the Shift or Ctrl key. Once the orders are selected and highlighted in green, click Add to Scratchpad. At this point the system will start the process of converting the inpatient medications to outpatient orders. Any dose conversion logic configured will apply here.  

The following screen represents a discharge reconciliation for which every possible action has been recorded. The description for each action is shown here. 

1. A home medication order that was discontinued during medication reconciliation. The user may choose to undo this action by highlighting the row and selecting the Undo button beneath the scratchpad. 
2. A prescription order that was modified during medication reconciliation. The original order indicated Twice a Day and was updated to Once a Day.  A modify action will discontinue the current prescription and place a new prescription with the new details. A modify action cannot update the strength of the medication being prescribed. In that scenario the originating home medication can be discontinued and a new medication ordered. 
3. These indicate orders that were Added from Home Medications to the scratchpad. Note the ‘missing details’ flag to indicate there are missing required details.  
4. A reported medication that is converted to a prescription at time of discharge. 
5. A prescription that is reordered at time of discharge. 
6. An inpatient medication that was not added to the final discharge list. This may be because a home medication is already documented or because it is a medication you are choosing to not continue on discharge. 
7. A new order has been added to the list of discharge medications for the client. 
8. A home medication that was held at time of admission, presenting a notification to the user during discharge reconciliation. 

Per the screen above, Reconcile & Sign is not available to the user until all inpatient medications have been designed as Add to Scratchpad or Hold. Additionally, any missing required details need to be completed prior to signing. During reconciliation, users will receive the same passive alerts indicating interactions as they do during order entry for both Orders This Episode and Home Medications. These alerts can be managed individually or at signing time.  

Just as for pre-admission episodes, users will have the ability to queue a discharge reconciliation for activation by the nurse or provider at the time of actual discharge. This should only be done when the provider is relatively certain that no adjustments will be made to the patient’s list after reconciliation completion. Once finalized, reconciliation will need to be restarted if any changes are required to either the home or inpatient medication list. 

Additional Navigation Notes

• The arrow indicators  in the middle of the right side of the window allow the user to fully expand the pre-admission medication list or the order details. Clicking once will expand the list up or down depending on the selection, clicking in the opposite direction will stop mid screen, and another click will expand full screen in the opposite direction. 
• The Restart Reconciliation button allows a user to restart a reconciliation. When selected, all current selections will be reset and the home and inpatient orders will be reloaded. 
• Partial reconciliation is not currently available in medication reconciliation. A user must take an action on all inpatient and pre-admission orders before restart reconciliation is available. 
• A nurse can perform an admission reconciliation on behalf of a physician by choosing the ordering physician at time of Reconcile and Sign. All order actions will still go to the physician for validation. 
• The discharge reconciliation does include the ability to manage details for multiple orders at once. This typically occurs if multiple orders are added to the scratchpad. Upon selecting one order, all order details will populate the order details screen. But upon selecting another order, the order details that populate will reduce to the three that can apply to all – Diagnosis, Refills, and Days Supply. This saves the user from having to select each individual order. If a detail for any of those three orders exists on the order prior to selection, an entry must be entered to overwrite. Otherwise, the system will assume no change is required.  

• Once Discharge Reconciliation is complete, it cannot be redone. Any new additions to the Home Medications list will need to be added manually to the inpatient medication list  If added to Home Medications list as well, these medications will be present for discharge reconciliation. 
• Users will be able to navigate to other areas of myAvatar and return to Discharge Reconciliation with their work saved. However, should a user navigate to either Home Medications or Orders This Episode, they will be prompted that their work will be lost if they continue. 
• If a user navigates to another client and navigates back, they will be presented with a message indicating that new orders may have been added. They will be given the option to continue with their in-progress reconciliation or restart. If they choose to continue, any new inpatient or home medications will not be reflected in the orders presented for reconciliation.