Medication   Reconciliation   Technician   Standard   Workflow
Process   Description:
Medication   Reconciliation   is   the   process   of   making   a   good   faith   attempt   to   obtain   a   patients   prior   to   admission   medication   history,   which   is   eventually   reconciled   against   a   patients   admitting   medication
list.
Reconciliation   involves   identifying   and   clarifying   intentional   and   unintentional   discrepancies.
An   accurate   and   reliable   medication   history   taken   on   admission   enables   the   continuation   of   appropriate   therapy   and   ensures   the   patients   care   is   seamless   when   transferring   from   home   to   hospital   or   from   one   healthcare   facility   to   another.
Who   Must   Use   this   Process?

Pharmacists   conducting   medication   histories,   Pharmacy   Technicians
Process   Notes:

A   patients   medication   history   should   be   completed   as   soon   as   a   patient   is   identified   under   the   prioritization   criteria

Patients   will   be   interviewed   by   the   Pharmacy   technician   in   the   order   generated   by   the   prioritization   criteria.
Other   sources   may   be   contacted   to   verify   information.

The   Pharmacy   technician   will   make   an   accurate   entry   into   Epic   of   the   patients   current   medication   regimen   as   communicated   by   the   patient,   family   member   ,care   giver   or   SNF   etc

The   Pharmacist   reviews   the   entry   in   EPIC   for   accuracy   and   to   identify   any   discrepancies

Discrepancies    should   be   discussed    with   the   physician/   floor   pharmacist   as   appropriate
Process   Requirements:

CICARE   training

Medication   reconciliation   technician   training   &   evaluation

Epic   training

Introduction   to   the   ED   set   up   (zones,   work   flow,   multidisciplinary   interaction,   ED   resources)
Process   and   Detailed   Steps
Definitions
A.
Track   Board   –   a   screen   view   of   the   electronic   medical   record   (EMR)   where   progress   of
Emergency   Department   patients   is   viewed   and   updated.
Includes   patient   demographics,   chief   compliant,   emergency   severity   index   score,   PTA   med   list   status,   etc.
B.
ESI   (Emergency   Severity   Index)   –   a   triage   system   of   screening   and   classifying   patients   to   determine   acuity   and   resource   needs.
ESI   numbers   range   from   1 ‐ 5;   the   lower   the   number   the   more   acute   the   patient.
C.
Care   Everywhere   –   a   screen   view   of   the   patients’   profile   in   the   EMR   which   contains   the   patients’   specific   records   held   with   Sutter   Health   affiliates.
Only   available   and   accessible   when   a   patient   has   agreed   to   release   the   information.
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D.
Rx   Dispenses   –   a   screen   view   of   the   patients’   profile   in   the   EMR   of   the   pharmacy   dispense   history   available   from   the   Surescripts   system.
Provides   information   on   dates   of   dispensing,   medication   name,   strength,   dosage   form,   quantity   dispensed   and   dispensing   pharmacy.
E.
Rx   Snapshot   –   a   screen   view   in   the   patients’   profile   of   the   patients’   treatment   team,   current   and   past   medical   problems,   vitals,   laboratory   results   and   medications   ordered.
Completing   the   Daily   Tasks   List
1.
Pharmacy   technicians   should   complete   items   on   the   daily   task   list   relevant   to   their   shift   (Appendix
A).
Pharmacy   technician   obtains   a   list   of   prioritized   patients   from   the   ED   Track   board   (Appendix   B   pages   2 ‐
8)
1.
Log   onto   EPIC   and   click   on   the   ED   Track   board   Icon.
2.
Prioritize   the   patient   list   in   order   of   priority,   as   follows:   a.
All   patients   in   the   Ready   for   Admit   Screen   b.
Patients   from   the   PTA   Meds   Review   screen:   a.
ESI   1   &   2   b.
ESI   3   with   the   following   (in   order   of   priority):
Age   >   65
Multiple   Meds   >4
Co ‐ morbidities   c.
CDU   requests   d.
ESI   4   &   5   e.
Patient’s   in   the   waiting   area   of   the   ED   yet   to   be   prioritized   and   allocated   ESI   numbers.
Permission   should   be   obtained   from   the   patient   prior   to   interview   as   this   is   an   open   area.
3.
On   occasion   the   hospital   census   may   be   full,   and   patients   may   “board”   in   ED   extension.
At   the   discretion   of   the   pharmacist,   technicians   may   go   to   this   area   to   complete   medication   histories.
Pharmacy   technician   prepares   the   Admit   Med   Rec   report   and   interviews   the   patient   (Appendix   B   pages
8 ‐ 14)
1.
Pharmacy   technician   prints   Admit   Med   Rec   report   for   the   first   3   prioritized   patients
2.
Pharmacy   technician   reviews:   a.
Chief   complaint   b.
Past   medical   history   c.
Previous   dispense   history   (Rx   dispenses),   if   available   d.
Care   everywhere   medication   list,   if   available   e.
Reconcile   outside   medications   list,   if   available   f.
ED   notes   in   some   cases   to   obtain   pertinent   medication   information.
3.
Pharmacy   technician   checks   ED   notes   to   ensure   patient   is    at   their   bed   before   proceeding   to   interview   them
4.
Enters   patients’   room   and   uses   CICARE   to   introduce   themselves   and   explains   the   process   to   the   patient.
5.
Verifies   the   patient   using   two   identifiers   (   Name,   date   of   birth)
6.
Verifies   the   patients   preferred   pharmacy(s)
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7.
Using   Admit   Med   Rec   report,    interviews   the   patient   using   mainly   open   questions   and   closed   questions   if   needed   (Appendix   C   can   be   used   as   a   guide)   a.
Can   you   tell   me   what   medications   you   are   currently   taking?
Do   you   have   any   of   your   medications   or   a   medication   list   with   you?
Do   you   have   anyone   who   helps   you   with   your   medication?
Do   you   live   at   home   or   in   a   facility?
b.
Do   you   know   if   that   is   a   tablet/   capsule/   liquid   etc?
Do   you   know   what   formulation   that   is?
c.
Do   you   know   what   strength   you   take?
How   many   do   you   take   and   how   many   times   a   day?
Clarify   the   time   of   day   if   necessary.
When   did   you   take   the   last   dose   of   the   medication?
d.
If   the   patient   is   taking   it   differently   to   our   records   –   Did   your   doctor   advise   you   to   adjust   your   dose   or   did   you   decide   by   yourself   to   take   your   medication   differently?
e.
Do   you   take   any   other   medications   that   you   can   remember?
Any   over ‐ the ‐ counter   medications,   medicated   creams/   ointments/   patches,   use   any   inhalers,   injections,   eye   drops/   ear   drops,   sprays,   seasonal/   allergy   medications?
f.
Asks   gender/   age   appropriate   questions   –   are   you   using   any   oral   contraceptive   medication?
Do   you   use   any   hormone   replacement   therapy?
Are   you   using   any   testosterone   preparations?
g.
Do   you   use   any   dietary/   vitamin   supplements,   herbal   medications   or   supplements?
8.
Technicians   should   ensure   to   return   and   interview     patients   who   are   with   other   staff   members,   or   when   they   are   interrupted   during   patient   interviews,   and   obtain   the   remainder   of   the   medication   history.
9.
Technicians   should   endeavor   to   return   as   soon   as   possible   to   start/   complete   the   interview.
10.
For   the   period   of   time   the   patient   remains   in   the   ED,   the   Pharmacy   technician   must   make   as   many   good   faith   attempts   as   possible   to   interview   the   patient   to   obtain   a   complete   history.
11.
If   the   patient   refuses   to   be   interviewed   or   the   Pharmacy   technician   is   unable   to   obtain   a   medication
history   e.g.
patient   is   unconscious,   has   altered   mental   status,   does   not   recall   their   medications,   the
Pharmacy   technician   must   contact   other   sources   (see   below)   and   make   a   good   faith   attempt   to   obtain   a   medication   history   during   the   time   period   while   the   patient   remains   in   the   ED.
12.
Interviews   should   be   concluded   in   the   usual   CICARE   fashion.
Pharmacy   technician   assesses   information   given   by   patient   &   verifies   medication   history,   if
necessary
1.
Pharmacy   technician   may   contact   other   sources   to   verify   all/   some   of   the    information   given   by   the   patient
Examples   of   sources   include:   a.
Caregiver/   Family   b.
Pharmacy   c.
Primary   Care   Provider   d.
Nursing   Home/   Facility   e.
Clinics   f.
2.
The   Pharmacy   technician   should   use   their   discretion   to   decide   whether   it   is   pertinent   to   obtain   certain   information   e.g.
we   would   not   call   a   pharmacy   to   obtain   the   brand   of   multivitamin   the   patient   is   taking.
3.
A   maximum   of   60   minutes   should   be   spent   actively   working   on   obtaining   a   medication   history   for   a   patient   and   using   all   available   sources.
4.
The   Pharmacy   technician   should   refer   any   discrepancy   or   issue   which   they   judge   to   be   outside   their   scope   of   practice   to   the   pharmacist   on   duty.
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Pharmacy   Technician   annotates   the   Admit   Med   Rec   report
1.
Pharmacy   technician   uses   the   legends   system   to   annotate   the   Admit   Med   Rec   report   (Appendix   D).
2.
Completes   the   audit   label   for   each   Admit   Med   Rec   report   (instructions   Appendix   E).
The   following   criteria   must   be   completed:   a.
Tech   initials   b.
Date   c.
Time   started   d.
Time   finished   e.
Total   time   f.
Interview   time   (minutes)   g.
Additional   sources   time   (minutes)   h.
Number   of   discrepancies   i.
Epic   input   time   (minutes)   j.
Number   of   attempts
Pharmacy   Technician   updates   PTA   medication   list   on   EPIC   immediately   after   interviewing   each   patient   (Appendix   B   pages   15 ‐ 17)
1.
Pharmacy   technician   updates   the   medication   list   in   ED   navigator>PTA   med   document   list
2.
Each   medication   should   be   updated   with:   a.
Medication   name,   strength,   dosage   form   b.
Directions   of   administration   c.
Taking/   not   taking   d.
Last   dose   taken
3.
Entries   should   be   deleted   if   they   are   erroneous   and   re ‐ entered.
4.
Medications   absent   from   the   list   should   be   entered   with   the   criteria   listed   in   2.
5.
If   technicians   were   unable   to   obtain   some   information   regarding   the   medication(s)   e.g.
strength   they   should   use   the   generic   Epic   entry   e.g.
Vitamin   C   PO
6.
Yellow   notes   may   be   added   to   highlight   discrepancies   associated   with   a   medication.
A   yellow   note   should   only   highlight   discrepancies   between   what   was   prescribed   and   what   the   patient   is   taking.
a.
In   the   interview,   if   a   discrepancy   is   found   the   following   questions   should   be   asked:   b.
Did   the   MD   change   this   dose/tell   you   to   stop   taking   or   was   this   by   patient   choice?
c.
Why   was   this   change   made?
d.
How   long   ago   was   this   change   made?
e.
To   the   best   of   our   ability,   the   yellow   note   should   then   say,   for   example,   “Pt   was   prescribed   2   tabs   daily   but   patient   elected   to   take   1   tab   daily   starting   two   weeks   ago   because   he   was   dizzy”.
f.
Use   of   yellow   notes   should   be   minimized   and   only   reserved   for   communicating   key   information.
7.
Administration   instructions/   notes,    should   be   used   if   additional   information   is   obtained   during   the   interview   that   elaborates   on   how   the   patient   was   taking   the   medication   at   home   (eg.
takes   for   back   pain   as   needed,   applies   to   scalp),   that   information   is   to   be   included   in   the   administration   instructions   and   not   in   a   yellow   note.
8.
Rx   dispenses   and   Reconcile   outside   medications,   functions   can   be   used   to   add   medicines   to   the   PTA   med   lists.
a.
Technicians   will   click   on   the   “reconcile   outside   medications”   link.
b.
For   each   medication   listed,   technicians   should   select   “add”   or   “discard”.
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c.
Select   “discard”   if   the   medication   is   an   exact   match   for   a   medication   on   the   PTA   Med   list   d.
If   “add”   is   selected:   a.
Technician   will   need   to   enter   the   medication   sig   (dose,   route,   frequency)   b.
Erase   information   in   the   “instructions”   field   c.
Click   “file   &   close”   d.
Editing   that   list   does   not   change   the   Sutter   Health   record   e.
Entries   should   contain   as   much   information   as   possible.
Pharmacy   technician   marks   as   Pharmacist   review   pending   (Appendix   B   pages   18 ‐ 19)
1.
Under   Med   List   Status   Pharmacy   Technician   selects   one   of   the   following:   a.
Pharmacist   review   pending   if   the   medication   list   is   complete.
Pharmacy   technician   enters   one   of   the   following   +   phrases:   a.
.ptr
+phrase   (Pharmacy   Technician   reviewed   PTA   med   with   ***)   and   notes   the   sources   used.
Time,   date   and   user   are   automatically   recorded   by   Epic.
b.
.nil
+   phrase   (Patient   states   no   current   regular   medication).
Time,   date   and   user   are   automatically   recorded   by   Epic.
c.
Incomplete   if   the   medication   list   requires   some   follow ‐ up   actions.
Pharmacy   technician   can   enter   .ptu
+   phrase   (Pharmacy   technician   unable   to   assess   due   to   ***)   and   the   reason   stated.
Time,   date   and   user   are   automatically   recorded   by   Epic.
Pharmacy   technician   hands   off   annotated   Admit   Med   Rec   report
1.
Each   report   should   be   forwarded   to   the   pharmacist   immediately   after   the   Epic   entry.
2.
Pharmacy   technician   places   the   Admit   Med   Rec   report   in   the    in ‐ tray   in   the   ED   satellite   for   pharmacist   review   unless:   a.
There   are   unresolved   or   unusual   discrepancies   which   should   be   handed   off   to   the   pharmacist   in   person.
Pharmacist   checks   the   annotated   Admit   Med   Rec   report   against   the   PTA   med   document   list
1.
See   Standard   Process   Description:   ED   Pharmacist   and   Medication   History   (Appendix   F)
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Appendix   A
S:\Med   Reconciliation\Daily   Tasks.docx
Appendix   B
S:\Med   Reconciliation\Pharmacy   Forum\Med   Rec   Workflow   ED  ‐  illustrated.docx
Appendix   C
S:\Med   Reconciliation\Tech   Training\Scenarios   &   Data   Collection   Form\Med   Rec   Data   Collection
Form.docx
Appendix   D
S:\Med   Reconciliation\Medication   Reconciliation   Technician   Key.docx
Appendix   E
S:\Med   Reconciliation\Definitions.docx
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