D.5 - NMVAHCS - MCP 11-53 - Medication Reconciliation.pdf

MEDICATION RECONCILIATION

New Mexico VA Health Care System

Albuquerque, NM

MCP11-53

Signatory Authority

Director NMVAHCS

Rescinded Document

MCP 11-53 Medication Reconciliation, dated

December 25, 2020.

Service Line

Chief of Staff

Effective Date

March 2021

Responsible for Updates

Chief of Staff

Recertification Date

March 31, 2026

1. POLICY

a. This medical center policy (MCP) establishes guidelines for performing a medication reconciliation that identifies and resolves medication discrepancies during patient visits within the New Mexico Veterans Affairs Health Care System (NMVAHCS). Providers must maintain and communicate accurate medication information for all patients. This communication will occur within all patient contact, including: during outpatient visits, Inpatient admissions, Transfers, at discharge and Virtual Visits.

b. The information providers use to reconcile medications include but are not limited to medication name, dose, frequency, and route.

c. The medication reconciliation process must occur when the patient encounters a provider in the outpatient setting, is admitted, transferred between services, and discharged from the inpatient setting.

d. All patients receive a complete updated list of medications when discharged from the facility after an inpatient hospitalization and after any outpatient provider visit.

2. JUSTIFICATION

This policy exists to ensure compliance with Directive 2011-012, Medication Reconciliation, dated March 8, 2011, and Joint Commission Standards.

3. SUMMARY OF CHANGES

a. Reformatted.

https://ba.va.gov/s/va-policy-search

March 2021 MCP 11-53

b. Updated to include Virtual Visits.

4. DEFINITIONS/ACRONYMS

a. Medication. This includes prescriptions, sample medications, herbal remedies, vitamins, pharmaceuticals, or over-the-counter drugs, vaccines, diagnostic and contrast agents used on or administered to persons to diagnose, treat, or prevent disease or other abnormal conditions; radioactive medications; respiratory therapy medications, parenteral 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. The medication definition does not include enteral nutrition solutions (which are considered food products), wound supplies, or oxygen and other medical gases.

(1) Short-term medications: No medication refills and for use for less or equal to 30 days.

(2) Long-term medications: Any medication with refills and for use greater than 30 days.

b. Medication Reconciliation. Medication reconciliation ensures that we maintain and communicate accurate patient medication information. The process of comparing the medications a patient is taking (and should or should not be taking) with the following medication data sources:

(1) local active VA prescriptions,

(2) remote active VA prescriptions,

(3) non-VA medications,

(4) recently expired VA prescriptions (120 days),

(5) recently discontinued VA prescriptions (120 days),

(6) inpatient/clinic orders and pending medication orders.

c. Medication Reconciliation List. A list that captures the medications the patient is currently taking (or should not be taking) in comparison to the available medication data sources. This includes:

(1) Changes made during an inpatient stay or outpatient visit;

(2) Medications the patient reports he/she is or is not taking (including vitamins, herbals, remedies and over the counter medications as stated above);

(3) Medications on the non-VA medication list; and

(4) Medication regimens from other VA facilities as well as outside (non-VA) medical records;

(5) Recently expired medications;

(6) Recently discontinued medications.

d. Good Faith Effort. It may be challenging to obtain accurate medication information from a patient and or surrogate. However, the provider's good faith effort to obtain this information from the patient and or other sources meets the intent of medication reconciliation.

e. Provider. for medication reconciliation: Physicians, dentists, optometrists, licensed independent practitioners (LIP) and pharmacists.

f. Virtual Visit. An internet-based episode of provider-patient interaction. Virtual visits can provide health services online and help manage chronic diseases, including diabetes, asthma, hypertension, heart failure and HIV.

(1) Verbal review of the medication list should occur between the provider and the patient and documented in the medical record as required for a face-to-face visit.

(2) Does not require a print-out for patients before the encounter because of the visit's virtual nature. A reconciliation review should be offered to the patient after the visit and delivered via mail, email, etc., as requested by the patient.

5. RESPONSIBILITIES

a. Chief of Staff. The Chief of Staff is responsible for ensuring:

(1) All VA providers are adequately trained and educated on the medication reconciliation process and understand its importance in the scope of quality patient care and patient safety.

(2) All VA providers are knowledgeable about their roles and responsibilities concerning medication reconciliation.

(3) All VA providers are provided inter-provider, inter-departmental, inter-facility, communication, which conforms to all relevant VA and Veterans Health Administration

(VHA) privacy policies and Federal law.

b. Providers. Providers are responsible for

(1) Completing the medication reconciliation following this policy. During the admission process, during outpatient visits, when transferring a patient to another service or facility, when discharging and during virtual visits.

(2) Ensuring that all medication changes during the patients' visit or stay are reflected in the medication list, including determining whether previous outpatient medications need to be changed or discontinued based on orders written during the inpatient stay.

All changes, discontinuations and new orders must be reconciled and entered into the outpatient medication list before writing the Discharge Instructions. The Medication

Reconciliation Discharge Template is embedded in the Discharge Instructions to facilitate the process.

(3) Ensuring the provider, nurse or pharmacist provides education and instructions on the discharge medication list to the patient/ surrogate /receiving facility personnel. If medications are new and meet criteria per VA policy for additional education, the pharmacist will provide this educator to the patient/ surrogate and document the occurrence of such education. Provide the patient/surrogate/receiving facility personnel a list of the Discharge Instructions containing the updated reconciled list of medications.

(4) Generating the medication reconciliation note using the NMVAHCS Transfer template that reflects the active inpatient medications that the patient is receiving when transferring a patient between services

(5) Reviewing the patient reviewed medication list with the patient/surrogate.

(6) Documenting a plan to address medication discrepancies commensurate with the severity of the discrepancy and the risk of patient harm.

(7) Documenting and reporting adverse events and reporting close calls to the Patient

Safety Manager.

(8) Providing education to the patient/surrogate as necessary for them to understand the importance of their medications and the need to take them as prescribed.

(9) Completing the visit-specific medication reconciliation documentation using the

NMVAHCS facility template;

(10) Determining if additional education is necessary or if the patient/surrogate should go to Open Pharmacy for further review;

(11) Instructing the patient/surrogate to check out to obtain a printed reconciled updated medication list.

c. Medical Support Assistants. Medical Support Assistant is responsible for:

(1) Printing the medication list, giving the list to the patient and instructing the patient to review the list before seeing the provider

(2) Providing the patient with an updated medication list when they are checking out of the clinic appt.

d. Health Technician, RN, Licensed Practical Nurse (LPN). The Health Technician, RN and LPN are responsible for:

(1) Facilitating updates to patient reviewed VA medication list if needed.

(2) Inquiring if the patient is seeing a non-VA provider.

(3) Remind the patient to document any medications the patient is receiving from any

Non-VA providers.

(4) Reminding patients to document any medications used that are not prescribed.

(5) Giving the patient reviewed medication list to the provider.

e. Clinical Service Chiefs. Clinical Service Chiefs or designees are responsible for:

(1) Ensuring all providers they supervise are aware of this policy and the procedures associated with medication reconciliation.

(2) Assuring compliance with monitors.

f. Patient Safety Managers. Patient Safety Managers are responsible for:

(1) Collating, trending all medication reconciliation monitoring data.

(2) Following up reported close calls from the clinical services and

(3) Reporting to the Patient Safety Committee, Quality Board and Clinical Executive

Board.

g. Chief of Pharmacy. Chief of Pharmacy is responsible for:

Providing access to pharmacy consultation for questions.

h. Patients and or surrogates. Patients or surrogates are expected to be responsible partners in their care and provide accurate information regarding their medication regime to their providers.

6. OTHER PARAGRAPHS

None

7. REFERENCES

a. VHA Directive 2011-012, Medication Reconciliation, dated March 8, 2011.

b. Joint Commission Standards

8. RESCISSION

MCP 11-53 Medication Reconciliation, dated December 25, 2020.

9. REVIEW

This MCP will be reviewed 120 days before recertification or sooner if there are changes to governing documents cited in the references above.

10. RECERTIFICATION

This MCP is scheduled for recertification on or before the last working day of February 2026.

This MCP will continue to serve as local policy until it is recertified or rescinded. In the event of contradiction with national policy, the national policy supersedes and controls.

SIGNATORY AUTHORITY

/S/ Andrew M. Welch

New Mexico VA Health Care System Director

NOTE: Signature remains valid until rescinded by appropriate administrative action.

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