Auditor Guide for
Discharge Audit Tool
Medication Reconciliation Discharge Audit
Updated: February 9, 2016
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Auditing
Why Measure?
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Measurement and sustainability
Measurement is for learning and not for judgement
It is vital to ensure that new MedRec processes and tools are consistent and effective in reducing
medication errors and improving patient safety.
Frequent measurement gives timely feedback to staff and physicians and helps keep them engaged
in making changes to improve the process.
By completing audits at the unit level we are able to learn how MedRec processes are working and,
based on the results, make specific changes to improve.
The measures collected in the audit help evaluate the improvement strategy.
Measures
Measure
NEEDED
Success Measure
More than 90% Patients with MedRec completed on Discharge
 Quality Measure
80% of the sample population with all quality elements
completed
Less than 10% of patients with one or more outstanding
discrepancies or omissions
 Outcome Measure
Who Will Audit
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The audit should be conducted by an independent healthcare provider (i.e. different than the
person completing the Discharge Tool or MedRec process).
The Person(s) undertaking the audit needs to be familiar with discharge processes on the unit being
audited.
When to Audit and how often
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The audit tool should be used to audit charts once the MedRec process has taken place.
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Discharge audits are conducted on a three (3) step ladder system depending on if the three (3)
measures of compliance goals are being met
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Step 1: Monthly until goal is reached
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Step 2: Then Quarterly for one year
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Step 3: Ongoing will be Bi-annually (every six months)
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Three (3) step ladder system
Step 1: Monthly
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Audits are to be conducted on a monthly basis when MedRec is implemented in your program
area/unit
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Audits will be submitted the last Monday of each month.
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If all three (3) measures of compliance goals have been successfully met for three (3)
consecutive months you will move onto Step 2.
Step 2: Quarterly
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Audits are to be conducted on a quarterly basis for one full year if all three (3) measures of
compliance goals have been successfully met for three (3) consecutive months in Step 1.
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Audits will be submitted the last Monday of March, June, September and December.
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Should the measures of compliance goals not be met the program area/unit will need to return
to monthly submissions (Step 1).
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If the three (3) measures of compliance goals were met at all quarterly submission points then
you will move on to Step 3 where data submission will only be required bi-annually (every 6
months)
Step 3: Bi-Annually (every six months)
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Audits are to be conducted on a Bi-annual basis going forward if all three (3) measures of
compliance goals have been successfully met for one full year in Step 2.
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Audits will be submitted the last Monday of June and December.
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Should the measures of compliance not be met the program area/unit will return to quarterly
submissions (Step 2). If the goals still are not met the unit will need to return to monthly
submissions (Step 1).
Four Elements of a Quality Audit
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Admission BPMH on chart available for review at discharge
Each medication from the admission BPMH is accounted for at Discharge
Complete medication information
Rationale included for changed and discontinued medications orders from the admission BPMH
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Sampling Strategy
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The recommended number of charts is 10 for baseline audits1 and 5 for ongoing audits as a
minimum standard.
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The MedRec Project Team will conduct the baseline audits.
When auditing, consider obtaining a list of all discharges in the past 72 hours.
For the ongoing audit of 5 charts, consider the following:
 For 5 or fewer discharges, audit all discharges.
 If between 6 and 9 discharges, audit the first five (in order of time discharged).
 If 10 or more discharges, audit every 2nd chart until five are reached (in order of time
discharged).
 It is important to vary the audit dates, as well as to audit on Monday or Tuesday to
capture weekend discharges.
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Definition of Baseline:
It is critical to collect baseline data to get a sense of what the issues are prior to implementing new
MedRec processes. A true baseline is collected prior to implementing any MedRec processes. If
MedRec has already been implemented in an area, then the first data collection entered will be
considered the baseline.
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Discharge Audit Tool
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Where to get and send the Audit Tool
CompassionNet (until PS Metrics Discharge Audit Tool available)
The Discharge audit tool is not yet available on Patient Safety Metrics (PS Metrics). It is scheduled to
be available by Fall 2015. In the interim, a temporary tool is available on the CompassionNet
Medication Reconciliation page.
Once on the MedRec page scroll down and click “MedRec Evaluation and Measurement.” Then click on
“Discharge Audit tool”
Where to send the completed Audit Tool
Once completed, scan the discharge audit tool to the Medication Reconciliation Project Team, Pharmacy
Technician’s email: Jessica.Currie@covenanthealth.ca using a multifunction scanner/printer/fax. To
email on your machine:
• On your touch screen press email - you may have to scroll down (If you cannot find the email
button, consult the owner’s manual for the machine)
• Type the email (Jessica.Currie@covenanthealth.ca) in the space provided
• Press send email
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Once available on Patient Safety Metrics (Coming by Fall 2015)
Each program area/unit will have a specific audit tool created with their demographic information
included on the top right side of the tool as well as program area/unit specific bar coding. Once you
have logged onto Patient Safety Metrics (PS Metrics) you will click on “Get Form” for your program
area/unit and then print. Tools may be photocopied from the original. Additional information on how to
use PS Metrics can be found on CompassionNet.
Where to send the completed Audit Tool (Coming by Fall 2015)
The Auditor will fax the audit tool in fine resolution to PS Metrics from a multifunctional printer/fax to
the number listed on the tool. To change the resolution on your fax machine:
• Press the “settings” button on your fax machine. (If your machine does not have a settings
button, consult the owner’s manual for the machine).
• Scroll through the settings until you see the “resolution” option.
• From the list of available resolution settings, select “fine”. The higher the resolution to which
your fax machine is set, the higher the quality of the faxes.
HOW TO: fill out the Audit Tool (applicable to both versions)
General Instructions
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Fill in bubbles completely (Black
permanent marker works best)
Do not colour outside of the line
Do not fold the form
Do not use a cover sheet
No extra markings or stains on the form
Do not hole punch before
faxing/scanning
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Specific Instructions for filling out either of the Audit Tools
Filling in contact, demographic
Current CompassionNet Discharge Audit Tool:
 In the top left of the tool, write the date, your
name and phone number
 In the space provided write your zone, site, unit
and program (the zone will be Covenant Health)
 This is required so that someone from The
MedRec Project Team may contact you if there
are problems with the scan/email.
 Each unit will need to print the tool off of
CompassionNet
 Forms may be photocopied from the original.
Once available on Patient Safety Metrics (Fall 2015):
 The top left of the audit tool includes a space to
write the auditor’s name and phone number.
 This is required so that someone from Patient
Safety Metrics or the MedRec Project Team may
contact you if there are problems with the fax.
 Each unit will have a specific audit tool created
with their demographic information included on
the top right side of the tool.
 Unit-specific bar coding will be included on the
form as well.
 Forms may be photocopied from the original.
Note: If the photocopy is not clear, a new form from the
Patient Safety Metrics system may need to be obtained.
 Fill in the appropriate year, month and day
bubbles for the date that the audit is being
conducted.
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If you are auditing patients on different days on
the same audit form, then write the most
recent date.
For filling in the information for the day of the
audit:
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For a single digit day of the month, e.g. for the
3rd, fill in the 0 on the first row and the 3 on
the second row.
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Filling in patient number and columns A, B, C and D
(This is the same for either tool)
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Patient Number:
• If a mistake* is made on data collection, fill in the “void” bubble for that patient and use another patient
line to enter the data correctly.
* Common mistakes include incorrect bubble(s) filled out, mixed up patient information, etc
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Column A – Was MedRec Performed at discharge:
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Fill in “YES” – if Discharge MedRec tool is located and completed in the chart (or process has been
completed in an IT system).
Fill in “NO” – if there is no Discharge MedRec tool in the chart, or form is blank, or process has not been
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completed in the IT system yet.
 If “NO” is filled out, do not fill in bubbles for Columns C to G.
Note: The aggregated data from this column will be used as a measure of percent (%) reconciled at discharge.
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Column B –Admission BPMH on chart:
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Fill in “YES” – if admission BPMH is present in chart or IT system.
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Fill in “NO” – if no admission BPMH present.
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Column C – Every med in the admission BPMH has been accounted for at discharge:
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Fill in “YES” – if meds on admission BPMH have been accounted for at discharge.
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Fill in “NO” – if no admission BPMH present or if there were meds on admission BPMH that could not be
accounted for at discharge
Note: This is our outcome measure. If you respond “NO”, this means there are outstanding discrepancies
identified. It is not necessary to count all of the discrepancies. Once the first discrepancy/difference is found, fill in
“NO”. Using clinical judgement, if the Discharge MedRec tool appears incomplete/poorly done, the auditor will
inform the most responsible nurse and suggest redoing the Discharge MedRec Tool.
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Column D – Each medication on the Discharge MedRec tool has drug name, dose ± strength, route, frequency:
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Fill in “YES” – if all applicable medication information has been provided.
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Fill in “NO” – if there are missing components to the medication information.
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Filling in columns E, F, G and H
(This is the same for either tool)
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Column E ‐ Prescriber has documented rationale for discontinued and changed medications from the
admission BPMH at discharge:
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Fill in “YES” – if there has been documented rationale provided for all discontinued and changed meds
from the admission BPMH at discharge.
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Fill in “NO” – if there has not been documented rationale provided for all discontinued and changed
meds from the admission BPMH at discharge.
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Fill in “Unclear” – if documentation does not allow you to respond confidently.
Column F – Has the Discharge Med list been provided to the client/caregiver?
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Fill in “YES” – if there is documentation that the Discharge MedRec tool has been provided to the
client/caregiver.
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Fill in “NO” – if there is no documentation that the Discharge MedRec tool has been provided to the
client/caregiver.
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Fill in “Unclear” – if documentation does not allow you to respond confidently.
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Fill in “N/A”- if there are circumstances where this may not be applicable.
Column G – Has the Discharge Med list been provided to the next healthcare provider(s)?
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Fill in “YES” – if there is documentation that the Discharge MedRec tool has been provided to the next
healthcare provider(s).
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Fill in “NO” – if there is no documentation that the Discharge MedRec tool has been provided to the
next healthcare provider(s).
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Fill in “Unclear” – if documentation does not allow you to respond confidently.
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Fill in “N/A”- if there are circumstances where this may not be applicable.
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Interpreting and viewing the Audit data
What are the Measures and how are they determined?
Success Measure: This is the percent of patients with MedRec completed on discharge. Our goal is to be
at 90% or higher. On the audit sheet, this is question A.
Quality Measure: This is made up of four quality elements; Admission BPMH available for review at
discharge, each medication on the discharge list has the medication name, dose, strength, route and
frequency, every medication each medication is accounted for at discharge and rationale included for
changed and discontinued medication from the admission BPMH. On the audit sheet, these are
questions B-E. Our goal is to be at 80% or higher.
Outcome Measure: This is the amount of discrepancies or errors on the MedRec. Our goal is to be at
10% or lower. We determine this by looking at question C on our audit sheets.
Current
The Medication Reconciliation Project Team will extract the data from the completed Discharge Audit
Tools sent from each unit and create a graph to display the data. The graph will be sent to the Program
Manager to display on the MedRec audit board and discuss the results at regular staff meetings.
Patient Safety Metrics (Coming by Fall 2015)
The Patient Safety Metrics (PS Metrics) system, a web-based data submission and reporting system, was
designed to support teams in the collection and analysis of improvement data.
The Data entry and reporting component of PS Metrics is a secure environment accessible by approved
user-members to access and enter data, organization and member profiles as well as to run real-time
organizational reports. MedRec auditors submit their completed audit tool to PS Metrics and authorized
users can view their data in real-time.
Covenant Health | Interpreting and viewing the Audit data
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