1. Medication Reconciliation for Facility Discharges
A step-by-step process using CPRS

2. Purpose of this presentation
To familiarize you with the medication reconciliation process at the time of hospital discharge for patients that will be discharged to another facility such as a skilled nursing facility (SNF), nursing home, or inpatient rehab center.
To avoid medication errors at the time of hospital discharge.
To practice the discharge process using a test patient in CPRS.

3. Disclaimer
This set of slides will go through the process of reconciling medications at discharge ONLY for patients admitted to the hospital and who will be discharged to another facility.
A different process is used if the patient is to be discharged to home (this will not be discussed in these slides).

4. Overview of the discharge process
Step 1: Discuss and review the discharge medications with your team and inpatient pharmacist.
Step 2: Ensure the inpatient and outpatient medication lists are accurate.
Step 3: Complete discharge paperwork

5. Step 1: Discuss and review the discharge medications with your team and inpatient pharmacist.
Review medications that were discontinued during hospitalization but will be resumed at the facility.
Review which medications were discontinued and will NOT be resumed at the facility.
Review which medications had a change in dosing or frequency/time of administration
Review which medications are new for the patient

6. Step 1: Discuss and review the discharge medications with your team and inpatient pharmacist.
Your inpatient pharmacist may write a “Pharmacy Discharge Medication Review” note to document medication changes to the home medication list during the hospitalization. Use this note to help you complete the rest of the discharge paperwork.
Sample Note:

7. Step 1: Discuss and review the discharge medications with your team and inpatient pharmacist.
If the patient will only be temporarily in another outpatient facility, the medications listed in “Outpatient Medications” on the “Meds” tab will resume upon discharge home from that facility.
If there is a new home medication that will be continued after discharge from the outpatient facility, order this prior to starting the discharge paperwork.

8. Step 2: Ensure the inpatient and outpatient medication lists are accurate.
Open CPRS and select your patient
Click on the “Meds” tab at the bottom of the screen

9. Step 2: Ensure the inpatient and outpatient medication lists are accurate.
Medications can be sorted by expiration date (default), order status, or alphabetically by clicking on “View” from the toolbar.
Inpatient facilities can continue medications on the current inpatient medication list.

10. Step 2: Ensure the inpatient and outpatient medication lists are accurate.
To start a new outpatient medication that is currently an inpatient medication:
Select the medication from the Inpatient medication list. Click “Action” and then select the “Transfer to Outpatient” option.
Then select “Release transferred orders immediately”

11. Step 2: Ensure the inpatient and outpatient medication lists are accurate.
To start a new outpatient medication that is not on the inpatient medication list:
Click on the “orders” tab
Click on “Pharmacy”
Click “Outpatient Meds”
Search for the desired medication and enter the order details (dose, frequency, refills, etc)

12. Step 3: Complete discharge paperwork
Medication changes at the time of discharge are recorded on a note called “Discharge Instructions”
The inpatient facility is provided with a copy of this document at the time of discharge so this must be 100% accurate.
For patients discharged to an inpatient facility, you MUST import the current inpatient medication list when writing this note.

13. Step 3: Complete discharge paperwork
To begin your “Discharge Instructions” note:
Click on the “Notes” tab at the bottom of the screen
Click on “New Note”
Select “Discharge Instructions” from the list of note titles
Click “OK”

14. Step 3: Complete discharge paperwork
Once the “discharge instructions” note has been started, fill out all fields in the form including:
Date of discharge
Diagnosis
Procedures performed during hospitalization
Future appointments
Suggested plan for follow up
Location that patient is discharged to
Review of discharge medications (Current Inpatient Medications MUST be imported here)
New medications or altered medications
Discontinued medications
Medications with food/drug interactions
Over the counter medications
Are medications being sent to the pharmacy window?
Pain discharge plan
Discharge diet
Physical activity and dietary restrictions
Signs and Symptoms to watch for
Wound care and Other instructions

15. Step 3: Complete discharge paperwork
Click this box to import the current inpatient medication list into the discharge instructions.

16. Step 3: Complete discharge paperwork
Once you fill in all elements of the form, select “Finish” to review the note.
Review the “Active Inpatient Medications” carefully and take note of the status (Active vs Pending) and the “Stop Date” for each medication.
All medications with status listed as “Pending” should be changed to “Active”, otherwise the inpatient facility may not dispense the medication to your patient.
If a medication needs to be continued indefinitely, delete the “Stop date”, otherwise the inpatient facility may stop this medication on the date listed.
For medications that need to stop on a certain date, make sure that a “Stop Date” is listed.

17. Step 3: Complete discharge paperwork
Review the entire “Discharge Instructions”
You must delete the section of the note “Active Outpatient Medications”
There should only be one list of medications, the “Active Inpatient Medications”
Once the note is 100% accurate, click “sign note now”
This note can be forwarded to the patient’s PCP, the PCP’s nurse, and any other health care provider by right clicking on the body of the note and selecting “Identify additional signers”
Forwarding this note to the PCP’s nurse will allow the nurse to arrange follow up per the recommendations on the discharge instructions.

18. Common errors/pitfalls to avoid
Forgetting to import the “Inpatient Medication List” when writing the Discharge Instructions.
Forgetting to cancel medications that are no longer appropriate.
Forgetting to delete the “Active Outpatient Medications” from the Discharge Instructions.
Forgetting to remove the “Stop Date” when medications are to be continued indefinitely.
Forgetting to include a “Stop Date” when a medication is to be stopped after a certain period of time.
Forgetting to change “Pending” status to “Active” on the Discharge Instructions.
Using this discharge process for a patient who is to be discharged directly home (This process is described in a different PowerPoint presentation)