Medication reconciliation is a formal process for creating the most complete and accurate list possible of a patient’s current medications and comparing the list to those in the patient record or medication orders since the health change status of the patient. The steps in medication reconciliation are seemingly straightforward. For a newly hospitalized patient, the steps include obtaining and verifying the patient’s medication history, documenting the patient’s medication history, writing orders for the hospital medication regimen, and creating a medication administration record. At discharge, the steps include determining the post-discharge medication regimen, developing discharge instructions for the patient for home medications, educating the patient, and transmitting the medication list to the follow-up physician. For patients in ambulatory settings, the main steps include documenting a complete list of the current medications and then updating the list whenever medications are added or changed.
A comprehensive list of medications should include all prescription medications, herbals, vitamins, nutritional supplements, over-the-counter drugs, vaccines, diagnostic and contrast agents, radioactive medications, parenteral nutrition, blood derivatives, and intravenous solutions (hereafter referred to collectively as medications). Over-the-counter drugs and dietary supplements are not currently considered by many clinicians to be medications, and thus are often not included in the medication record. As interactions can occur between prescribed medication, over-the-counter medications, or dietary supplements, all medications and supplements should be part of a patient’s medication history and included in the reconciliation process.