Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation

Building a Flowchart Diagram

Below are questions to help you flowchart your current process, new process, or process redesign at admission, transfer, and discharge.

Admission

Medication History:

1. Who obtains a medication history?
2. What is captured during a medication history interview?
3. When is a medication history obtained?
4. Where is the medication history documented within the patient's medical record?
5. How is a medication history documented (i.e., structured paper form; electronic entry; etc.)?
6. How do you monitor and measure that medication histories are obtained and documented appropriately?

Comparison (Reconciliation):

1. Who compares (reconciles) medication orders to medication histories?
2. What is the process for reconciliation?
3. When does reconciliation occur?
4. Where is documentation found in the medical record that reconciliation took place?
5. How do you identify which discrepancies require clarification?
6. How do you monitor and measure that reconciliation is occurring?

Orders:

1. Who places medication orders?
2. What is the process for ordering medications?
3. When are medications usually ordered in relation to obtaining a medication history?
4. Where are the ordering decisions for each of the patient's current medications documented (i.e., documenting plan to continue blood pressure medication the patient takes at home)?
5. How are discrepancies resolved?

Resolution:

1. Who follows up on unintended medication discrepancies?
2. What is the mechanism to resolve unintended discrepancies?
3. When does the followup occur?
4. Where is the documentation located within the patient's medical record indicating that discrepancies were resolved?
5. How do you document resolution or outcome of the intervention?
6. How do you monitor and measure that unintended discrepancies were actually resolved?

Intra-Facility Transfer

Comparison (Reconciliation):

1. Who compares (reconciles) medications upon transfer?
2. What is the process for reconciling orders a patient is currently receiving in the sending unit compared to orders the patient will be receiving at the new level of care?
3. What is the process of comparing these orders to the patient's pre-admission medication list?
4. When does reconciliation occur in preparation for transfer?
5. Where is the documentation that reconciliation took place?
6. How do you identify discrepancies requiring clarification during reconciliation?
7. How do you monitor and measure that reconciliation is occurring?

Orders:

1. Who reviews current medication orders and updates orders in preparation for new level of care?
2. What is your process for review and updating medication orders in preparation for transfer?
3. When does the review and update occur?
4. Where is the intent/plan for each medication documented in relation to the medication orders in preparation for transfer?
5. How are medication orders handled in preparation for transfer (i.e., rewritten)?

Resolution:

1. Who follows up on unintended medication discrepancies?
2. What is the mechanism to resolve unintended discrepancies?
3. When does the followup occur?
4. Where is the documentation located within the patient's medical record indicating that discrepancies were resolved?
5. How do you document resolution or outcome of the intervention?
6. How do you monitor and measure that unintended discrepancies were actually resolved?

Discharge

Medication Discharge List and Reconciliation:

1. Who reviews, reconciles, and updates the patient's medication list in relation to current orders in preparation for discharge?
2. What is the discharge reconciliation process?
3. When does this occur?
4. Where is the updated, complete medication history documented within the patient's medical record?
5. How is the patient's medication list documented in preparation for discharge?
6. How do you monitor and measure that the patient's medication list was updated and a complete list was given to the patient highlighting any changes?
7. How do you communicate the patient's updated, complete medication list to the next provider of service and who provides this communication?

Resolution:

1. Who follows up on unintended medication discrepancies at discharge?
2. What is the mechanism to resolve unintended discrepancies at discharge?
3. When does the followup occur?
4. Where is documentation located within the patient's medical record indicating that discrepancies were resolved?
5. How do you identify discrepancies requiring clarification during reconciliation?
6. How do you document resolution or outcome of the intervention?
7. How do you monitor and measure that unintended discrepancies were actually resolved?