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 Connect Care "Medication List" is a record of medications in active use by a given patient at a given time.
Encounter-level Medication Reconciliation
The collection of the best possible medication history (BPMH) occurs in both outpatient and inpatient workflows. Reconciliation of prior with ongoing and new medication use occurs at care transitions (e.g., admission, discharge, transfer). The goal is clear documentation of what a patient should be taking, with explanation of any variance between intended and actual medication.
Event-level Medication Reconciliation
Identifying and accounting for differences between outpatient (home) and encounter (admission, discharge, transfer, etc.) medication use is a minimum use norm expectation. Reconciliation is also important when certain major events (e.g., surgical intervention, critical care) occur within an encounter. If peri-encounter medication review has already been done, then peri-event review is easy to fit into pre-op and post-op workflows.
System-level (outside) Medication Reconciliation
The clinical information system (CIS) has interfaces to external digital health records, including legacy non-Connect Care CISs (e.g., Metavision, Meditech, eCLINICIAN) and the Alberta NetCare Portal electronic health record. Connect Care users may be alerted to medication information appearing in these external systems, sometimes with the ability to import data into the Connect Care Medication List as part of medication reconciliation workflows.
The presence of outside information that might be reviewable or importable is indicated with an "e" (Care Everywhere) icon appearing at the top right of the patient storyboard in a patient chart open in Hyperspace. Clicking on this opens a "Reconcile Outside Info" chart activity where allergy, medication, problem list or immunization data from external systems may appear. Medication data from eCLINICIAN and other legacy CISs can usually be imported, sparing the need to re-type medication details.
An early interface to the Pharmacy Information Network proved premature and is retired until more a more reliable interface can be deployed. Some stray PIN outside reconciliation notices may remain, but can be easily removed: