From: Medication reconciliation at admission and discharge: a time and motion study
Admission: prior to meeting the patient
Reading the medical chart
Reviewing patients’ charts for demographic information, reading the admission note, reading admission orders, reviewing allergies and other health or medication related information that may have been collected at the emergency room or in prior, recent admissions, and taking notes.
Reviewing lab results
Reviewing patients’ lab results and writing notes.
Calculating and recording creatinine clearance, phenytoin, and other clinical values.
Admission: discussion with patient
Greeting patients or family members. It also may include asking patients who gets their medication from the pharmacy.
Community drug list
Interviewing the patient about his or her prescription medications at home.
Interviewing patients to determine if they know why they are taking the drugs they have prescriptions for (therapeutic intention). Most of the time this question is not asked directly or the patient initiates this discussion on his or her own.
Interviewing patients about the frequency at which they take their drugs.
Adherence to medication
Asking patients if they actively take their medications as prescribed and if not, why not.
Asking patients if they take any over the counter medications such as acetaminophen, vitamins, or herbal remedies.
Asking patients about any allergies they may have to medication.
Asking patients for the phone number or exact address of their community pharmacy.
Permission to exchange medication information
Informing patients that their pharmacy will be contacted in order to get information on their community medications. Sometimes the permission is implied by providing the pharmacy’s coordinates, and is therefore timed under pharmacy coordinates, but often clinicians directly ask the patient if they allow them to call their pharmacy.
Admission: external research on medication history
Phoning the patient's family member or caregiver
Communicating with the patient’s family member or caregiver by phone.
Phoning the patient's CLSC/nursing home
Communicating with the patient's CLSC or nursing home by phone.
Searching for pharmacy coordinates
Performing a Google search on the internet to find out patient's pharmacy's phone number. This task also includes time searching for the patient's CLSC phone number, if applicable.
Communicating with the pharmacy
Communicating with the pharmacy by phone with the purpose of obtaining a fax of the patient’s medication profile, validating their compliance, determining how they manage their medications (using a pillbox or other methods), and asking about recent medication changes.
Waiting for pharmacy fax
Measures the wait-time between calling the patient's community pharmacy to ask for a fax of their medication list, and actually receiving it. While waiting, the pharmacist either does other work unrelated to this patient, or they do other tasks for this admission such as reading the patient's lab results (in which case, the time would also be recorded under the appropriate task heading).
Admission: reconciliation of medications and documentation
Clarifying discrepancies with patient
Discussing with patients any discrepancies between what the pharmacy’s community drug list, and the list of medications that patients had verbally provided.
Documenting/Reviewing admission medication list
Documenting the community drug list and reviewing in hospital medications that were given to the patient at admission. This task also includes time spent looking at vital signs from the patient’s clipboard, if this occurs.
Discussing recommendations with in-hospital prescriber
Discussing recommendations by the pharmacist/pharmacy student for the patient's in-hospital medications with the physician or resident.
Documenting recommendations for in-hospital prescriber
Documenting recommendations regarding the patients’ in-hospital medications in the chart progress notes.
Timing any other notes the clinician records that do not fall in the above categories but that are related to the patients’ medications.
Discharge: preparing the discharge prescription
Reviewing in-hospital medications and labs
Reviewing in-hospital medication lists and labs, in any of the following locations: paper medical chart, nurse’s kardex, hospital pharmacy database, or electronic hospital medical record.
Reviewing community medications or chart notes
Reviewing available documentation on patient's community medications or any other chart notes.
Discussing in-hospital medications with patient
Discussing in-hospital medications with the patient.
Discussing community medications with patient
Discussing medications the patient was taking in the community prior to his or her hospital admission with the patient.
Writing the discharge prescription
Writing or reviewing the discharge prescription, if both were done at the same time. Other actions timed under this heading included: communicating with other health professionals regarding questions about the patient or his or her medications, using online programs to research drugs, or searching for allergies in the patient's chart.
Reviewing the discharge prescription
Reviewing the prescription by the prescribing physician, resident or pharmacist before signing it. When the discharge prescription was written by a physician or resident, this task included time spent by the pharmacist reviewing it before the physician or resident signed it.
Discussing the discharge prescription with the patient
Discussing the discharge prescription with the patient and/or family/caregiver. It may also include documenting explanations about the discharge prescription for the patient.
Consulting with other clinicians about the discharge prescription
Asking other collaborating health professionals questions regarding the patient’s discharge prescription (in person, or by phone).
Revising the discharge prescription after consulting other clinicians
Editing the discharge prescription after having consulted other clinicians about it.
Revising the discharge prescription after consulting the patient
Editing the discharge prescription after having discussed it with the patient.
Other final documentation
Preparing any other documentation regarding the patient’s medication plan such as documentation that may be needed by the community pharmacist.
Faxing discharge information to community pharmacy
Faxing a summary of medication changes or the discharge prescription to the community pharmacy.
Any additional time spent on discharge medication reconciliation by the health professional before the research assistant arrived to start timing. For example, in some cases the pharmacist had started looking at the patient's chart before the research assistant had arrived to start timing.