Medication Documentation Norms
What is it?
Medication documentation is about how medication decisions are recorded, communicated, validated, implemented, supported and followed. It promotes safe, effective and appropriate drug therapy as part of patient-centred care. The Medication List is a record of medications in active use by a given patient at a given time.
A few terms have specific meanings in medication documentation workflows:
Medication Management: Patient and health team collaboration to optimize safe, effective and appropriate drug therapies.
Best Possible Medication History (BPMH): Complete and accurate list of all of the medications a patient is taking, created using at least two information sources that include a patient or proxy interview.
Medication Reconciliation: Formal process in which healthcare Prescribers collaborate with patients to ensure accurate and comprehensive medication use information is communicated consistently across transitions of care.
Clinical Medication Review: Examination of patient medication use in the context of clinical conditions and interventions in order to improve health outcomes.
Reconciliation uses a BPMH to establish what a patient should be taking, and actually is taking, then clarifies changes, adjustments or discontinuations associated with the start or end of an episode of care. It also includes re-consideration of pre-encounter medications at the conclusion of the episode.
Why does it matter?
Medication-related error is a common cause of health system-associated harm, with miscommunication at the root of most misadventure. Ongoing maintenance and periodic review of a comprehensive medication list is essential for clinical decision support (e.g., drug-drug, drug-disease, drug-lab, drug-dose and drug-reaction checks), medication administration, adverse reaction surveillance, patient education, patient adherence and system-to-system health record transfers.
Medication reconciliation is particularly sensitive to norms. It can be inconvenient, but vitally important. It ensures that patient medications (prescribed and self-administered) are reviewed and validated at transitions of care and periodic reviews.
Who is responsible?
Many members of a multidisciplinary health care team can contribute to medication management. Roles, scopes of practice and resources vary in different settings. In any one practice context, there should be clear communication about which clinicians can assist with preparation of a BPMH.
Medication reconciliation is typically a Prescriber responsibility. Inpatient reconciliation is done by the admitting Prescriber(s). Prescribers are responsible for medications of their own ordering but must also consider effects of other Prescribers’ actions and ensure that subsequent Prescribers are supported with all the information needed to refill, prescribe and de-prescribe safely.
How is it done?
The collection of the best possible medication history occurs in both outpatient and inpatient workflows.
Medication review and documentation must be done at every inpatient admission, every new outpatient assessment, periodically for recurring outpatient care and at every discharge or inter-facility transfer event.
All medication orders (prescriptions) must be entered to Connect Care where it is the record of care.
Reconciliation of prior with new medications occurs at care transitions (e.g., admission, discharge, transfer) as well as periodically during ongoing disease management.
Good practice is reflected by clear documentation of any variance between intended and actual medication use and any reasons for change from prior to temporary or ongoing new medication lists. Medications can be corrected or marked discontinued in medication history and reconciliation processes, while new prescriptions are recorded through ordering activities.
