36C25718R0247-032.pdf

DEPARTMENT OF VETERANS AFFAIRS Policy Memoranda 11-14-88 South Texas Veterans Health Care System San Antonio, Texas 78229-4404 December 18, 2014

MEDICATION RECONCILIATION

1. PURPOSE: To establish policy and procedure at the South Texas Veterans Health Care System (STVHCS) to manage patient medication information by reconciling medications at all levels and transitions of the health care continuum. The purpose of reconciliation is to identify, address and document medication discrepancies as compared with the medication information supplied by the patient along with changes made during the episode of care.

2. POLICY: Medication reconciliation serves to ensure maintenance of accurate, safe, effective, and patient centered medication information by obtaining medication information from the patient, caregiver, or family members, comparing this information to medication information available in the VA electronic medical record (EMR) with non-VA medications, in order to identify and address discrepancies. All STVHCS Divisions (to include Acute Hospital Care, Outpatient Care; Long Term Care, Home Care and Behavioral Health) will be responsible to accomplish and appropriately document the Medication Reconciliation at every episode or transition in level of care.

3. DEFINITIONS:

a. Episode of Care: An admission, discharge, or, if in an outpatient setting, each time the patient sees a different provider, regardless of how many different providers the patient sees in one day.

b. Medication: Includes locally ordered at the treating VA facility, remote VA medications and/or non-VA medications. Medications also include vaccines, vitamins, sample medications, diagnostic/contrast agents, radioactive medications, respiratory therapy treatments, parental nutrition, blood derivatives, intravenous solutions (plain, with electrolytes and/or drugs) and any product designated by the Food and Drug Administration (FDA) as a drug. This definition does not include enteral nutrition solutions (which are considered food products), oxygen, and other medical gases.

c. Medication Discrepancy: Unintentional differences (omissions, commissions, inappropriate duplication, changes and/or additions) found in the patient’s medication information when compared to the medication information available in the EMR.

d. Minimal medication use: Usually prescribed/administered during a brief encounter, not involving other medication use, discharge prescription of medication, or any other changes in medication that the patient has been taking at home (“home meds”).

e. Non-VA medication: Ordered by non-VA providers, VA provider prescribed medications filled at non-VA pharmacies, herbals, over-the-counter medications, nutraceuticals and alternative medications.

f. Remote VA medication: Ordered at any other VA facility and viewed or imported via remote data view.

g. Transitions in care: Changes in setting, service or level of care, across the continuum of care, where medications will be administered, prescribed, modified, or may influence the care given – whether in an emergency department, an ambulatory clinic, a home care service, or other setting or service.

4. ACTION:

a. Outpatient Procedures:

(1) New/established patients presenting to the Emergency Department, Specialty and Outpatient Clinics of STVHCS with providers with prescribing privileges will have their medications reconciled at each visit and/or episode of care.

(2) Providers with prescribing privileges will obtain and document a complete and accurate list of the patient’s scheduled and non-scheduled VA and non-VA medications from the patient and/or caregiver at every

POLICY MEMORANDUM 11-14-88

encounter utilizing the VA EMR. The list will include the name, dose, route, frequency and purpose of the medications.

(3) Every reasonable effort will be made to obtain medication information from the patient and/or other sources, but if unable to do so, the reason will be documented in the EMR.

(4) Compare and document the medication information obtained from the patient and/or other sources with the medication information available in the VA EMR, to include active and recently expired medications, remote medications and non-VA medications. Identify the discrepancies and the actions taken to update medication information into the VA EMR at the end of the episode of care.

(5) Situations may arise when a discrepancy is identified and the medications are outside the scope of practice of the health care team member performing Medication Reconciliation. If these discrepancies cannot be resolved at the time of the visit, judgment must prevail, weighing the discrepancy against the risk of patient harm. The patient can be instructed to contact the provider who ordered the medication to discuss options for resolution. The health care team member can request an additional signer or write a targeted addendum to the note, when access to necessary resources and communication strategies exist.

(6) Provide written information (name, dose, route, frequency and purpose) to the patient / resident / caregiver or family member on the medications that the patient should be taking at the end of an episode of care. Document the updated medication list in the “Med Reconciliation” note in the VA EMR system.

(7) Document verification that discharges information in the VA EMR is consistent with discharge instructions provided to the patient/ family/caregiver at the end of the episode of care.

(8) Explain the importance of managing medication information to the patient / resident / caregiver or family at the end of an episode of care. Instruct the patient to share the medication list with his/her provider (s) of care and to have the information updated when medications are discontinued, doses are changed or new medications are added.

(9) Encourage the patient to carry medication information at all times in the event of emergency situations.

b. Inpatient Procedures

(1) Inpatient Procedures Inpatient Admission:

(a) For all inpatient admissions, the history and physical will include a complete list of VA and non-VA medications (home meds) the patient has been taking obtained from the patient and/or caregiver.

“Home meds” should include the name, dose, route, frequency and purpose of the medications. If the history and physical is written prior to the admission date then an update on the admission day must be completed and documented, noting any change or lack of change in the list. The provider will make every reasonable effort to obtain this information from the patient and/or other sources but if unable to do so, will document the reason.

(b) Whenever possible, compare the information obtained from the patient, caregiver or family member to the medication information available in the VA EMR, to include active and recently expired medications, remote medications and non-VA medications in order to identify and address discrepancies.

(c) Document discrepancies identified and take action to update medication information at the end of the episode of care into the VA EMR (including changes relevant to the episode of care).

(2) Inpatient Procedure - Transfers:

When a patient is transferred to a different setting, service or level of care, the receiving provider who will be writing the new orders must complete the reconciliation process by documenting actions in the VA EMR.

Medications ordered are compared to medications on admission. Discrepancies are identified, resolved and documented.

NOTE: When care is transferred within the hospital, the current provider(s) informs the receiving provider(s) about the current inpatient medication list and documents the communication. When inpatients are transferred from one level of care to another, but remain on the same service, formal documentation of the medication reconciliation process is not required.

(3) Inpatient Procedure- Discharges:

(a) For inpatients who are being discharged, a member of the team (Intern, Resident, Physician Assistant, Nurse Practitioner, or Attending Physician) will complete the STVHCS Medication Reconciliation Inpatient/Discharge Progress Note. This serves as a communication of relevant medication information to and between the appropriate members of the VA and non-VA health care teams.

The discharge note will be compared and reconciled to the original list of home meds documented in the admission history and physical note.

(b) Every effort will be made to provide the patient and/or caregiver a printed Medication Reconciliation note at the time of discharge.

(c) Ensure discharge information in the VA EMR is consistent with discharge instructions provided to the patient, caregiver or family member at the end of the episode of care.

(d) Explain the importance of managing medication information to the patient, caregiver or family at discharge. Instruct the patient to give the medication list to his/her primary care physician and other healthcare providers to update the information when medications are discontinued, doses are changed or new medications are added. Encourage the patient to carry medication information at all times in the event of emergency situations.

(e) Patient information may be forwarded to a facility outside of the Department of Veterans Affairs (VA) only if the patient consents to this communication of his/her personal health information.

(4) Reporting:

(a) Document and report adverse events and close calls into the VA EMR and the VA Adverse Drug Event Reporting System (ADERS).

(b) Service Chiefs are responsible to work with Quality Management to ensure provider compliance through quantitative and qualitative audits.

5. REFERENCES: TJC Standards 2014, National Patient Safety Goals 2014, and STVHCS 2013 Bylaws and Rules of the Medical Staff.

6. RESPONSIBILITY: Chief of Staff (11C)

7. RESCISSION: STVHCS Policy Memorandum 11-11-88, dated August 4, 2011

8. RECERTIFICATION: December 2019

(Signature on file)

MARIE L. WELDON, FACHE

Director

Attachments (2) Attachment A - Explanations and References – Documentation Requirements for Patient Education Attachment B - Fact Sheet – Documentation Requirements for Patient Education

DISTRIBUTION: A & C

Explanations and References

The Office of Inspector General Medication Management Review

Documentation Requirements for Patient Education

Explanations

(1) According to the VHA Medication Reconciliation Directive 2011-012, all Medical Centers, Clinics and associated facilities where Veterans receive care are required to initiate medication reconciliation at every episode or transition of care where medications will be administered, prescribed, modified, or where medications may influence the outcome of the care provided.

(2) VHA Handbook 1907.01 refers to documentation requirements in outpatient progress notes that include but is not limited to the evidence of medication reconciliation, follow-up treatment plan, and patient instructions.

(3) The Joint Commission (TJC) National Patient Safety Goal 03.06.01 focuses on the risk points of medication reconciliation; Element of Performance (EP)-4 requires that patients when discharged from the hospital or at the end of an outpatient encounter receive written information about their medications.

This includes that patients (and/or care givers) receive specific information about the names, dosages, routes and frequencies, and purposes of newly prescribed, changed, and discontinued medications specific to the day of the encounter.

(4) TJC Primary Care Medical Home Option Medical Home Option Ambulatory Care Accreditation Program, Provision of Care 02.03.01 refers to education and training based on patient comprehension.

Thus providers must adjust their medication reconciliation and education approaches based on patient’s comprehension.

(5) TJC Rights and Responsibilities of the Individual 01.01.03 respects the patient’s right to receive information in a manner he or she understands. Many patients require alternative form of communications that include patients who (a) speak and/or read languages other than English; (b) have limited literacy in any language; (c) have visual or hearing impairments; (d) are on ventilators; (e) have cognitive impairments; (f) are children.

(6) Facilities have options available to assist in communication with these individuals, such as interpreters, translated written materials, pen and paper, communications board, and speech therapy. It is up to the facility to determine which of available methods would best meet the need of an individual patient.

References:

(1) VHA Directive 2011-012: Medication Reconciliation.

http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2390

(2) VHA Handbooks 1907.01: Health Information Management and Health Records (Page 40).

http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=2791

(3) Joint Commission National Patient Safety Goals NPSG.03.06.01: Medication Reconciliation.

http://www.jointcommission.org/assets/1/6/HAP_NPSG_Chapter_2014.pdf

(4) Joint Commission Standard Provision of Care 02.03.01: The Joint Commission Primary Care Medical

Home Option Medical Home Option Ambulatory Care Accreditation Program.

http://www.jointcommission.org/assets/1/18/Primary_Care_Home_Posting_Report_20110519.pdf

(5) The Joint Commission Requirements Related to the Provision of Culturally Competent Patient-Centered Care Rights and Responsibilities of the Individual (RI). Provision of Care, Treatment, and Services (Pages 9-14). http://www.jointcommission.org/assets/1/6/2009_CLASRelatedStandardsAHC.pdf

Attachment A http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2390 http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=2791 http://www.jointcommission.org/assets/1/6/HAP_NPSG_Chapter_2014.pdf http://www.jointcommission.org/assets/1/18/Primary_Care_Home_Posting_Report_20110519.pdf http://www.jointcommission.org/assets/1/6/2009_CLASRelatedStandardsAHC.pdf

Office of the Assistant Deputy Under Secretary of Health for Clinical Operations and

Pharmacy Benefits Management Office of Medication Reconciliation Initiative

Fact Sheet

Office of Inspector General Medication Management Review

July 24, 2014

1. Should Medical Centers implement Fluoroquinolone-specific training, design Fluoroquinolone order-set or Fluoroquinolone prescribing consult?

No, such actions are unnecessary. VA Office of Inspector General (OIG) inspectors in their Combined Assessment Program (CAP) reviews focused on Fluoroquinolone antibiotics, to review the integrity of medication reconciliation programs and processes at VHA facilities. The OIG inspectors also assessed whether or not VHA facilities followed patient education provisions included in VHA policies, and The Joint Commission (TJC) requirements for medication management.

2. How the CAP review relates to TJC National Patient Safety Goal on Medication Reconciliation and VHA Polices?

TJC considers Medication Reconciliation as a part of Medication Management that clearly includes reference to the education provided to patient under the Standard on Provision of Care (PC) 02.03.01. It is imperative that all Medical Centers provide education and training to patients based on their needs and ability to learn and understand.

It is also essential that each provider adjusts their medication reconciliation and medication education approach based on the learning assessment of the Veteran, family or Caregiver. This requirement is referred to in TJC National Patient Safety Goal.03.06.01 under Provision of Care 02.03.01. VHA Directive 2001-012, Medication Reconciliation, will be revised to include reference to these existing patient education requirements that integrate medication reconciliation into standard care processes for medication education (Standard PC 02.03.0, Medication Management (MM) 06.01.03, PC 02.03.01, and PC 04.01.05.) hand-offs between providers (Standard PC.04.02), and transitions in care (Standard PC 02.02.01).

3. How should one document medication management?

Network and facility leadership are responsible for ensuring in the interim that providers have resources available to assist them in designing their note templates that improve and facilitates documentation.

The Medication Reconciliation Program Office will soon engage information technology and collaborate with the Office of the ADUSH for Clinical Operations to provide guidance on note templates, standardized documentation strategies. Following example in the interim is provided for your reference:

“Medication education and counseling for new medications added today was provided to the Veteran based on his individual needs. This included why the medication was prescribed, how they should take it and for how long, what to expect from it, and what happens if medication is not taken as prescribed. By signing this note I certify that patient or caregiver or family member understood my instructions. A copy of the updated medication list was also given that included the medications added, changed, and/or discontinued today.”

4. Where can I get more information?

References are in Attachment A. Additionally, please review following SharePoint for more information: http://vaww.infoshare.va.gov/sites/MedRecon/default.aspx

Attachment B http://vaww.infoshare.va.gov/sites/MedRecon/default.aspx