1. Nursing Education Medication Reconciliation Patient Safety Initiative
Last updated: May 2015

2. Outline MedRec Basics MedRec Champions Important Dates
Admission, Transfer, Discharge
Overview and responsibilities
Measurement
Resources

3. What is Medication Reconciliation?
Patient Safety Initiative
Goal:
Develop a structured process to ensure that comprehensive and accurate medication information is collected and follows the patient’s journey during key transitions of care (admission, transfer and discharge).
Accreditation Canada ROP Requirement
The collection of a patient’s medication history is not new.
Minimize adverse drug events and medication errors at key transitions of care
Enhance transparency of information between healthcare providers and the patients across key transitions of care
Patient Safety Initiative to minimize drug errors and adverse drug events
Structured & formal process to:
identify the most complete and accurate list of medications
ensure careful evaluation of medications being added, changed or discontinued at key transitions of care (admission, transfer and discharge)
communicate, document and reconcile medication lists at key transitions of care
Accreditation Canada Required Organizational Practice (ROP) Requirement
What is new is the creation of a structured process to ensure the medication history is comprehensive and accurate and that all the discrepancies are addressed.

4. Key Transitions of Care
Different processes are in place as patients/residents move through different care settings. The Transition points are: Admission, Transfer and Discharge. We have developed a one page process handout to show all the different duties and responsibilities of each discipline.
MedRec structured process for implementation:

5. Admission MedRec

6. Admission
Best Possible Medication History (BPMH) is the cornerstone of the MedRec admission process.
BPMH is:
a medication history
a reference point for decisions to continue, discontinue or modify the medication regimen during key transitions of care
acts as the one “source of truth”
serves as medication orders on admission
(once reconciled and signed by prescriber)

7. BPMH Sources used to obtain history Date/Time the history completed
All prescribed home
Medications [including
Over-the-counter (OTC) medications
if they were PRESCRIBED to pt.]
Self-prescribed
Medications – (for information purposes only)
Additional Comments (information purposes only)
Reconciliation section
(Prescriber Use Only)
Prescriber signs & includes date and time of reconciliation
Page #s
If prescriber would like to order any of the patient’s self-prescribed medications, they must do so on a Prescribers Order sheet separately

8. Divisions of Authority to Complete
LEFT SIDE:
Medication History
(may be completed
by a licensed Health
Care Professional; this
includes, but is not
limited to, prescribers)
RIGHT SIDE:
Prescriber Use Only
Section of BPMH
Health care professional means an individual who is a member of a regulated health discipline, as defined by the Health Disciplines Act
[Alberta] or the Health Professions Act [Alberta], and who practices within scope and role.

9. Admission
A BPMH may be completed prior to, or alongside, all other admission orders being written (Proactive/Prospective Model) or
After initial admission orders have been written (Retroactive/Retrospective Model).
In either case, a BPMH should ideally be completed within 24h of admission.
Proactive: The admission BPMH is created prior to medications being ordered.
Retroactive: The admission BPMH is completed after the admission orders have being written. 25
8.6

10. Prescriber Reconciliation
The Prescriber Reconciliation Section can be completed either:
Pre-op or
Post-op
This will be decided by the Admitting Prescriber on a patient by patient basis
Proactive: The admission BPMH is created prior to medications being ordered.
Retroactive: The admission BPMH is completed after the admission orders have being written.
Ensure you are checking the chart for BPMH orders Pre-op and Post-op, but note that the BPMH can only be used as an order and scanned to pharmacy once

12. Direct admit from another facility
Patients who already have a completed admission BPMH from another site (copy faxed to your site).
In this case:
The BPMH will not serve as inpatient orders, but as a history/reference only.
A new BPMH is not to be completed.
Exception to the rule!!
This is because the BPMH is intended to represent HOME medications.
For example, patient admitted at RAH – admission BPMH completed there. Then the patient was directly sent to GNCH from RAH. At GNCH, a new BPMH is not required to be done; the team is to refer to the RAH BPMH. This is what we would call an external transfer, technically.
This way, when the patient is discharged from GNH, they can refer back to the original BPMH. The patient needs to know what has changed from their HOME medications.

13. Where will the BPMH be kept?
The BPMH will be kept in the Patient Care Orders Section (pink sheets) of the chart
It will be the top page of the section and be placed opposite the pink sheets
This is so the BPMH is easily accessible for review when the prescriber writes their orders

14. BPMH Tool: Late Entries
New information may be learned about the patient’s HOME medications after the initial BPMH is processed.
Any licensed health care professional may document the new information so the home medication history is as accurate as possible
If there is no room, start a new admission BPMH page and renumber all associated pages
If new information is learned about the patient/resident’s preadmission medications after the initial BPMH is completed and signed, it is still important to capture this new information. Write a late entry on the BPMH tool itself. If there is room on the original BPMH, write “Late Entry” along with the name, dose, frequency and route of the medication, date, time and your signature. If there is no room, start a new Medication Reconciliation tool and renumber all associated pages. Additionally, write this information in the progress notes and notify the prescriber to address the discrepancy.

15. Late Entries/ Addendums
Write “Late Entry” and the name, dose, route and frequency of the medication
Date, time and sign your entry
Notify the prescriber to address the discrepancy
Do NOT process/scan to pharmacy again
Any orders needed are to be written on the Patient Care Order (Pink) sheets C
SCANNED

16. What are my responsibilities?
PRESCRIBERS will be completing the BPMHs (not nursing)
Nursing will however be responsible for the documentation and notification of prescriber re: any late entries
Alternatively, you can flag to your Charge
Also, flag to your charge nurse if your patient has been admitted more than 24h and they do not have a completed BPMH in their chart.
Check to see if BPMH is used as orders Pre-op and Post-op
BPMH can only be processed as orders once (either Pre-op or Post-op)
If you discover a missed/incorrect home medication after the BPMH is already completed and processed.
Or if there were any changes to what was written above. Or consult the team’s pharmacist if you are unsure.

17. Transfer MedRec

18. Transfer A change in service, and/or level of care within the facility
ex. Grey Nuns Surgery to Grey Nuns Internal Medicine 
If the attending physician changes/rotates but the patient remains cared for by the same service, this is not considered a transfer
Within-service bed changes are not considered transfers
When the doctors on the same service rotate through on a weekly/biweekly basis, this is not a transfer.
Important to stress here the “common lingo” of transfer and how the word is misused.
a change in service, service provider, and/or level of care within the facility (eg. unit-to-unit transfer including from the intensive care unit to medicine unit and/or from vascular surgery to internal medicine)

19. Is there a tool for transfer?
There is no paper “tool”, but a neon green sticker will be used.
It is signed/dated/timed by the Sending and Receiving prescriber and included with any transfer orders written.
A sticker will be placed on the Patient Care Order by the UNIT CLERK at the time of transfer
This sticker/stamp is a way for prescribers to formally document in a standardized fashion that they have reviewed the BPMH and current medications prior to patient transfer.

20. Receiving a Patient within the Facility
If the Surgery Program is receiving a patient from another service, the Receiving Prescriber will sign the MedRec Transfer sticker acknowledging the BPMH medications and current medications have been reviewed
Good to know about it in case any prescribers on your team ask. You can still provide information and support, as well as remind them!

21. Sending a Patient within the Facility
If the Surgery Program is sending a patient to another service, the Sending Prescriber will sign the MedRec Transfer sticker acknowledging the BPMH medications and current medications have been reviewed
Exception: “Vascular IMCU Transfer Orders” PPCO will have a check box on the last page to indicate when this task is completed.
The PPCO reads: The above orders were created upon review of the patient’s current medications and Best Possible Medication History (BPMH)
Good to know about it in case any prescribers on your team ask. You can still provide information and support, as well as remind them!

22. IMCU to Ward – GNCH Only
Prescriber will check off this box (No sticker will be required)
Page 3 of the PPCO – just before signature.

23. What are my responsibilities?
Nursing has no official responsibility at transfer
Be aware of the process
help to remind prescribers this needs to be done on transfer of service within-hospital
Good to know about it in case any prescribers on your team ask. You can still provide information and support, as well as remind them!

24. GNCH - Vascular Service Patients Only
Discharge MedRec
GNCH - Vascular Service Patients Only
Note:
For all Non-Vascular Surgery Patients (i.e General Surgery, Ortho Surgery, Gyne Surgery etc), Discharge MedRec will not be completed. Please continue with your current Discharge Process.

25. Discharge
Refers to the end of service provision by the care facility
i.e. the patient physically exits the current facility and subsequently goes home or to a different care facility
Discharge to another facility: This refers to moving between facilities, where the patient physically exits the current facility and goes to another health facility setting (ex: to another hospital, long-term care facility).
Discharge to home/community : This refers to when the patient physically exits the current facility and subsequently goes to home/community setting (ex: to home, independent living, group home).
Tip: “Elvis has left the building” and is not returning (Case number is closed)

26. Transfer vs. Discharge Patient remains within the facility
From Service To Service
Patient physically leaves the facility
Out of the Hospital Setting (ex. Home, group home, independent living)
Out of a facility to another healthcare facility (ex. Grey Nuns Hospital to Youville Home)
CIS calls it a “transfer” from GNH to RAH, but in our terms, and health record’s terms, the correct terminology is DISCHARGE

27. Why a Discharge MedRec Tool?
Complete and accurate list of discharge medications
Plus a list of discontinued home medications
Once signed by prescriber:
Discharge medication orders and/or
Prescription (if a quantity specified)
This will replace current discharge prescription process
Includes OTCs and prescription medications.

29. Discharge MedRec Tool Date and Time Community Pharmacy Information
Prescribers Orders
Bubble Packaging
Requested
Discharge Medication
List
Discontinued
Medications (Prescribed
and Self-prescribed)
Prescriber Name and
Signature
Unit Contact Information
Prescription/Quantity
Page #s
Other Important Information
Community Pharmacy
Information

30. Discharge Tool: Two-ply
White ply:
Chart copy. If patient would prefer to take this copy in person to his or her pharmacy, a copy of it must be made for the chart. Clearly mark the photocopy as, “CHART COPY.”
Yellow ply:
Copy for patient/resident or caregiver for information purposes
Provide along with yellow copy of the Short Stay Discharge Summary Form.
Patient/caregiver will always receive this copy.
White ply:
Chart copy. If ordered, can be faxed to appropriate receiving community pharmacy and/or facility, as well as to the patient’s family physician. If patient would prefer to take this copy in person to his or her pharmacy, a copy of it must be made to keep in the chart.
Yellow ply:
Pre-marked as “not a prescription”. Copy for patient/resident or caregiver for information purposes (to be provided along with patient ply of the Short Stay Discharge Summary Form). Patient/caregiver will always receive this copy of the tool.

31. If Discharge Tool is faxed to a Community Pharmacy
In this case, the patient will ONLY receive the Yellow copy
Please ensure that if the tool is faxed for prescription purposes, the patient does NOT also receive the original (white) copy of the prescription – this would be the equivalent to the patient receiving TWO prescriptions!

32. What if the patient does not have a BPMH?
Effective the start date of implementation, a discharge MedRec tool is to be completed for ALL VASCULAR SERVICE patients being discharged
Even if there is no official BPMH in chart from admission.
Eventually all patients will have a BPMH so this will get easier. There will be a transition period where patients were admitted prior to implementation and may not have an official BPMH for comparison on discharge.
Please complete the discharge tool based on comparison with the chart medication history or pharmacist’s BPMH in progress notes.

33. What if the patient was admitted before MedRec implementation started?
These patients will not have a formal BPMH in chart
Effective the start date of implementation:
Discharge MedRec tool is to be completed for ALL VASCULAR SERVICE patients being discharged.
Eventually all patients will have a BPMH, so this will get easier.
Effective the start date of implementation:
Discharge MedRec tool is to be completed for ALL patients being discharged.
There will be a transition period where patients were admitted prior to implementation and may not have an official BPMH for comparison on discharge.
The discharge tool will be completed based on comparison with the chart medication history or pharmacist’s BPMH in Progress Notes.

34. Discharge directly to another facility
BPMH should be faxed to the receiving facility in addition to the discharge MedRec tool.
This provides the receiving facility with an understanding of the patient’s home medications, as a point of reference.
If the patient is being sent directly to another healthcare facility, it is important that in addition to sending the Discharge MedRec tool, the admission BPMH is faxed to them as well.

35. What are my responsibilities?
Help ensure the patient/caregiver always leaves the facility with yellow copy of the discharge MedRec tool
If the patient is additionally going to be given the white prescription copy (top copy) to take to their pharmacy, a photocopy will need to be made for the chart. Clearly mark the photocopy as “CHART COPY”
Liaise with the team pharmacist (if available) to ensure the patient has been provided explanation/education re: any medication changes.
Remember: If the prescription (white page) was already faxed, the patient leaves with the yellow copy ONLY.

36. Measurement and Evaluation

37. Measurement and Evaluation:
Auditing:
Auditing of admission and discharge MedRec will occur on a monthly basis by your unit’s designated auditor.
Measure
Question
Success Measure
Was MedRec completed?
Quality Measure
Was it done well?
Outcome Measure
Were there any discrepancies?
It is broken down into 3 measures. Check out your unit’s board for baseline data! Will be updated as audit results come in! Starts out monthly but if results are good, the frequency goes down.
The 5 quality elements are;
Two or more sources for the BPMH
Actual medication use verified by the patient/ family
Complete medication information (right name, dose, strength, route)
Every medication is accounted for in the admission orders and
Rationale included for changed and discontinued medication orders

38. MedRec Resources MedRec Flow Sheet/Responsibilities Poster
CompassionNet
Internal and External Resources
MedRec Policy
On Deck with MedRec Newsletters
MedRec Info Binders
Binders will be at Unit Clerk’s desk
MedRec Flow Sheet/Responsibilities Poster
In report room
MedRec Project Team
Will show on next slide how to get to the MedRec CompassionNet landing page.

39. MedRec Page: CompassionNet
1. Go to
2. Click “Care & Safety”
3. Then click on
Tip: Add to bookmarks, or a shortcut on desktop 
4. Then click on

40. If I have questions, who do I ask?
MedRec Champions
MedRec Team
During implementation dates: in-person and via pagers;
Pager #1: (780)
Pager #2: (780)
After implementation dates: via
To reach us instantly for those issues/questions that arise in the moment – page if you don’t see one of us!

41. Contact Us Do you have proposed changes to the MedRec work?
Complete a “Change Request Form” (available on CompassionNet)
Submit to:
Questions? Feedback?
All change requests will be brought forward to the MedRec Project Team and Project Executive Sponsor (if required) for discussion and decision. Submit to Meilai Ha, MedRec Project Coordinator.
Questions, feedback? Please the MedRec Team at the listed address.