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

This flow diagram highlights the potential gaps and barriers to effective communication about medication orders during discharge prior to redesign of a sound medication reconciliation process.

1. Patient being discharged from hospital.
2. Physician places discharge order.
3. Physician writes new prescriptions, if needed:
   1. Inconsistent practices for documenting and highlighting changes or updates for patient to home medication list.
4. Physician prepares discharge instructions referencing initial medication history within admission note ("history and physical"):
   1. No standardized, consistent practice for physicians to perform discharge medication reconciliation. Patient safety risks of documenting "resume home meds" not understated. Changes to initial medication history documented to progress notes/addendum may not be captured when preparing discharge notes.
5. Nurse counsels patient on discharge instructions and contacts physician if questions or clarifications needed:
   1. No standardized, consistent process for nurse to ensure patient receiving an updated home medication list. No consistent approach to address and rectify physician documenting "resume home meds."
6. Patient discharged.

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