Medication Reconciliation and the Medication Profile
When reconciliation is required, how to do one that finds the discrepancy, and keeping the profile true between visits.
Medication problems are the most common avoidable cause of a home health patient going back to hospital. Reconciliation is the intervention that catches them, and it is one of the highest-value things you do.
The rule
Ask at every visit whether there have been any medication changes.
If the patient has any new medication changes, you must perform a medication reconciliation each time.
Not at the next OASIS point. Not when you get round to it. That visit.
How to do one that actually finds things
Reconciling against a printed list finds nothing, because the list is what somebody intended. The discrepancy is the finding.
- Get every bottle in the house onto the table. Prescriptions, over-the-counter, supplements, creams, eye drops, inhalers, anything in the bathroom cabinet and the kitchen drawer.
- Include the old ones — bottles from before the last hospital stay are where duplicate therapy hides.
- Compare each against the current profile: name, dose, route, frequency.
- Ask what they are actually taking, which is a different question from what they have been prescribed. Ask without judgment; people stop medications for reasons that make sense to them.
- Count what is left against what should be left. The arithmetic tells you more than the answer does.
- Ask who fills them, who sets them up, and who reminds them.
What you are hunting for
- A medication stopped in hospital that the patient has restarted at home
- The same drug under brand and generic names, taken as if they were two drugs
- A dose changed on discharge that the patient has not noticed
- Anticoagulants started, stopped, or changed — see Anticoagulation and INR Management
- A new prescriber the rest of the team does not know about
- Something run out and not refilled, usually for cost
- High-risk combinations: sedatives stacked, NSAIDs on an anticoagulant, duplicate antihypertensives
The medication profile
The profile is the list the agency believes the patient is taking. Keeping it true is part of the job:
- Adjust it as you are notified — do not leave it for the case manager
- A photograph of the prescription bottle can be uploaded to the profile
- Verbal or confirmed orders are recorded here too — see Verbal Orders and Clarifications
A stale profile is worse than no profile, because the on-call nurse at 2am will believe it.
Teaching
- Purpose, dose, timing, and what each one is for — patients adhere to medications they understand
- What to do about a missed dose, per that specific drug
- Side effects worth reporting, and which need an urgent call
- A system that fits this patient: organiser, blister pack, alarm, or a caregiver
- Watch them use the system rather than asking whether they can
Teach-back at every visit, and document what they actually said — see Skilled Language — Writing What You Actually Did.
When you find a discrepancy
- Work out which version is correct, if you can
- Notify the physician the same day — see Talking to Physicians — SBAR in the Home
- Get the order, read back and recorded
- Update the profile
- Tell the patient plainly what changed and why
- Document who you told, what time, and what came of it