Medication reconciliation in home health
Building the most accurate list of what the patient really takes, then settling every difference with the orders.
Med rec, in four steps
At start of care, at resumption of care, and whenever a medication changes.
- 1. Collect
- Every source: the referral or discharge list, the bottles in the home, and what the patient says they take.
- 2. Compare
- Look for missing drugs, duplicates, different doses or times, and stopped drugs still being taken.
- 3. Resolve
- Settle each difference with the ordering provider and record what was decided.
- 4. Communicate
- Leave the patient an accurate list, and keep the care team on the same one.
Med rec at the bedside
Read the medications aloud or photograph the bottles. Each line shows what was heard or read, and is saved only when the nurse confirms it.
Required, for good reason
Medication lists drift at transitions: hospital to home, one prescriber to another.
- The comprehensive assessment
- It includes a review of all medications the patient is using (42 CFR 484.55).
- The OASIS
- Drug regimen review items M2001, M2003 and M2005 record issues found and followed up.
- Patient safety goal
- The Joint Commission's NPSG.03.06.01 asks for accurate, shared medication information.
Med rec questions
What is medication reconciliation?
Building the most accurate list of the medications a patient takes, with name, dose, frequency and route, and comparing it with the orders so every difference is resolved and recorded.
When does home health reconcile medications?
At start of care and resumption of care as part of the comprehensive assessment, and again whenever a medication changes.
Where do VisitNote's drug names come from?
From RxNorm's list of prescribable drugs, kept in VisitNote's own database. Searching doesn't send anything to an outside service.
Are bottle photos sent to an outside service?
No. Photos are read on VisitNote's own servers, and the lines they produce stay drafts until the clinician confirms them.
See it with your own notes.
A walkthrough of the phone app and the office workspace, with fictional patients.