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

The flowchart begins with Patient admitted to Hospital. Directly below this, in the center of the chart is:
Med Profile ("One Source of Truth")

Medication(s) Being Given (inpatient)
with space to record current and past medications.

Following that is:

Prescription(s)/Home Medications (outpatient)
with space to record current and past prescriptions.

However, after the patient is admitted, information does not flow straight to the Med profile, but can go in two directions. First, physician obtains and documents medication history in Med Profile. Physician completes the physician medication reconciliation form documenting ordering decisions for home medications. Then information can flow to the center, to the Med Profile, or down to Physician orders medications based on med list prior to admission and patient's current clinical status.

In the second direction, depending on the care unit, nurse and/or pharmacist verify medication history in Med Profile and Modifications made to home med list if new information is available.

Physician consulted regarding any changes. Then information can flow to the center, to the Med Profile, or down to: depending on the care unit, nurse and/or pharmacist reconciles medication history with current orders. Physician consulted regarding unintended discrepancies in relation to patient's care plan. Nursing (pharmacy) medication reconciliation form completed

Additional information:

1. Med Profile:
   • Single location for documenting and confirming home medications, share by all disciplines.
   • "One Source of Truth" for review and reconciliation of inpatient and outpatient medications.
   • Changes and updates to home medications clearly accessible (e.g., not "buried" in progress notes).
2. Forms:
   • Created standardized approach for physicians, nurses, and pharmacists for medication reconciliation.
   • Standardizes physician documentation regarding ordering decisions to identify intended versus unintended discrepancies.
   • Creates standardized process for nurses and pharmacists to identify, resolve, and document followup on unintended discrepancies and reduce re-work.
3. Sequence of Tasks:
   • Physician prompted to complete medication reconciliation (document home meds and ordering decisions) during admission or post-op order set.
   • Nurse (or pharmacist in ICUs) prompted to confirm history and reconcile with current orders.

Pharmacist performs final reconciliation and followup on unresolved or outstanding unintended discrepancies.

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