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How to do a medication reconciliation

Guest post by: Stephanie Kujawski, PharmD, BCPS

For this post I'm excited to welcome Stephanie Kujawski, PharmD, BCPS! Steph graduated from UNC-Chapel Hill in 2011 and completed a PGY1 residency in 2012. After practicing inpatient internal medicine for almost 8 years in 3 states, she is excited to transition to an ambulatory care neurology clinic in the coming weeks. She spends her free time trying to convince her wily quarter horse to stand still and hiking the Appalachians as much as possible.

This article was originally published on, a site dedicated to helping medical professionals simplify clinical topics, survive residency, and become better practitioners.

[PC]: I thought a lot of community pharmacists might be interested in reading just what it takes on the inpatient side to get a medication reconciliation done, and I also added some tips throughout on how you can help out your local hospitals.

Medication Reconciliation – How Can It Possibly Be THIS Hard?!

When Brandon asked me if I’d write a post about medication reconciliation (aka med rec), I actually laughed out loud.

Not because I regularly laugh at Brandon (rather, I laugh with Brandon), but because, much like Prince John’s quiet machinations to take Richard’s throne, med rec has literally been insidiously creeping in to take over my work life for the past few months.

So it was a timely request, to say the least!

How can this topic usurp my work life, you ask. Well, I suppose we should start back with some definitions, and then I’ll try to illustrate some of the areas where something that seems oh-so-simple becomes oh-so-complicated. Hence, the aforementioned coup.

What is a Med Rec?

So if I was to describe med rec to my non-healthcare system mom, I’d tell her that it’s a term used to encompass all the decisions made about a person’s medications when they change level or location of care.

This includes...

  • When a person is admitted to the hospital from home or a facility

  • When that patient is transferred from the ICU to the general medicine floor (and maybe even back to the ICU again)

  • When the patient is discharged from the hospital to home or a facility

  • And even after the patient is home and following up with his Primary Care Provider (PCP)

In each of these settings, a person requires various medications or doses that may or may not be their norm.

For example, the septic patient in the ICU may need stress dose intravenous hydrocortisone, but by the time they’ve improved enough to transfer to the floor, maybe they don’t need such high doses anymore.

So each time the patient moves, a provider should review the medication list and decide what is still necessary versus what can be stopped or adjusted. This review and decision process is medication reconciliation. Seems pretty straight-forward and simple, right?


So many areas where things can go awry.

In the spirit of trying to keep this as organized as possible, I’ll just say that, in the remainder of this post, we’re going to discuss the whos, whats, hows, and whens of med rec.

And we’re going to follow my favorite patient again. Why can’t Han just stay out of trouble?

A Case Study in Medication Reconciliation

Han was flying around the universe with Chewbacca in the Millenium Falcon when all of a sudden he developed severe chest pain and shortness of breath.

Chewy rapidly contacted Rebel 911, who brought him back to solid ground in their ambulance ship, and Han was rushed to the nearest medical center.

Han is now lying in a bed in the emergency room, when Nurse Leia enters to greet him (she’s multitalented, k?).

So at this point, the medical team needs to know more about Han. This includes knowing if he takes any medications at home so they can decide what to order for him as an inpatient. This info can also help the team know whether any of his home medications could be contributing to his current clinical picture.

But what if 4 other patients came into the ER at the same time? Who is the highest priority, and how is that decided?

This is a question for which we don’t really have a well-defined answer. Prioritization of patients both in the ER and on the hospital floors is difficult.

Many institutions utilize some sort of scheme, which might include:

  • Length of time from admission

  • Acuity of the patient

  • Number of medications on a prior medication list

  • Risk of readmission

But these aren’t exactly validated schemes or parameters, and further work is needed to determine how to prioritize taking a patient's medication history.

Also, who should be the one to ask Han about his home meds? Should it be Nurse Leia, Dr. Spock, or pharmacy personnel? If pharmacy, should it be a pharmacist, a pharmacy technician, or a pharmacy student? Does it matter?

If all 3 disciplines ask him about his home medications, will everyone end up with the exact same list?

Unfortunately, odds are that each person will walk away with a different list, especially if Han has an extensive list of medications.

Plus, what if Nurse Leia asks him early in his ER visit when his chest pain is still 10/10 and concentrating on anything is out of the question?

But is it really better for the pharmacy technician to try to get this information when his chest pain has abated…with the help of morphine?

Or will that leave him too loopy or sleepy to be reliable? So then should they get a Wookie translator and try to ask Chewy?


It’s easy to see how the reliability of the home medication list can vary greatly depending on what’s happening with a patient, whether family is around, and a patient’s baseline knowledge about what he is actually taking.

So why not wait until Han’s been admitted and feeling better a couple of days later on the inpatient floor?

Honestly, by that point, you may have missed the boat. What if Han’s missing a crucial home med or we’ve been giving him the wrong med or dose for 3 days straight?? Eek, you say!

This unfortunately happens. A lot.

Not to mention The Joint Commission is looking for medication histories to be completed within 24 hours of admission. So if you want to stay in their good graces (and keep your hospital accredited), then that's the metric you're aiming for.

How to Ask Questions During a Med Rec

The actual questions you ask (and how you ask them) is so crucial that it warrants further discussion.

You may get very different answers depending on whether you ask Han, “Do you take your metoprolol once a day?” or “How do you take your metoprolol?”

The latter’s where you uncover that, OMG, Han’s been taking his long-acting metoprolol 3 times a day. Whereas if you just ask the first question, Han is

possibly just going to agree with you, perhaps due to pressure of sounding confidently knowledgeable about his meds and not wanting to be “wrong.”

Or he just doesn’t know.

Maybe he didn’t get paid for his last (questionably legal) job, and he hasn’t been able to pay for his medications for the past 2 months.

This is why open ended questions are crucial for gleaning as much information as possible!

This is also why using MULTIPLE resources to complete a medication history is ideal. Meaning call the patient’s filling pharmacy – or pharmacies – to obtain a fill history and specific formulations.

[PC]: I don’t think I fully appreciated how much the med rec was the bane of every health system’s existence until I started working outpatient pharmacy inside a hospital. Help our inpatient friends out and take a couple minutes when they call to get a patient’s meds! By the time a patient has been passed around a few departments, med histories can really become a train wreck fast.

This is where you can confirm that Han was really prescribed metoprolol succinate once daily (even though he is adamant that he takes it 3 times a day). But then the filling pharmacy also tells you that he recently had a script for metoprolol tartrate TID, just 2 months ago.

HINT: intervention and education necessary here.

What Resources to Use During a Med Rec

Other resources can be used to play pharmacy detective. Skim through old records in the EMR or outpatient clinic notes, if they’re available. If you have access to insurance claim information through a special program, use that as a starting place. If the patient’s from a facility, call the facility to obtain a medication administration record (MAR), which will show exactly what that person’s been receiving!

[PC]: Bonus points - enroll your pharmacy in Surescripts medication history. Every time you fill a prescription, whether it is run as cash or through insurance, it will capture that data to pull up on hospital EMR systems so Stephanie has it when trying to take care of your patient who has shown up at her hospital. I enrolled our pharmacy and it was 100% free. The best place to start is your pharmacy software company.

Point being, use ALL your resources possible, especially when the patient or family reliability is questionable. You didn’t know you went to pharmacy school to be a detective, did you?

Who Should Complete a Med Rec?

In terms of who should do the history, multiple studies have demonstrated that pharmacy personnel, whether it’s a technician or a pharmacist, succeed the most in obtaining and documenting a thorough and accurate medication history.

This isn't just to pat ourselves on the back (though you can go ahead and do that now). We're in a uniquely strategic situation with our:

  • Baseline knowledge about medications and pharmacy fill process

  • Attention to detail (bordering on OCD for most of us)

  • Extensive training in patient interviewing techniques

  • Dedicated time and resources to medication history

That being said, we definitely can't discount the contributions of our partner disciplines!

Nurses and physicians usually have integral information from PCP or facility transfer phone conversations that can help us with our med rec, so make sure to touch base with them as well.

OK, to summarize, so far we’ve determined that pharmacy personnel trained in the Jedi ways of interview techniques (and who have filling pharmacy connections) should obtain a medication history as soon as possible after admission.

[PC]: Community pharmacists to the rescue! This is where patients having a recent Complete Medication Review (CMR) done can be a lifesaver. If they have had all their home meds resolved and documented on the Personal Medication Record (PMR), then all Stephanie has to worry about is resolving acute med discrepancies. Granted, the patient having their PMR on-hand is another battle, but you get my point.

What to Document in a Med Rec

What we haven’t discussed is what to document. I know, you’re saying well duh…you document the meds.


But do you document what Han was supposed to be taking according to the prescriptions, or do you document how he’s actually taking them?


This is an age old debate.

Because if you think ahead to the point of ordering medications on admission or at discharge, it becomes readily apparent that you could perpetuate an error if you document incorrect or unsafe instructions.

And this could affect the patient’s health.

Sometimes these errors are fairly easy to recognize and can be caught (e.g., the TID succinate), but often it’s not so easy.

For example, what if you found out from Han’s home pharmacy that, in addition to his metoprolol succinate script, he also had recently filled prescriptions for amlodipine and hydralazine.

He hasn’t been taking them per his report, but you put them on his list since they are technically actively prescribed medications. Then when the doctor goes to reconcile his medications at admission, he orders the amlodipine and hydralazine too.

The verifying pharmacist sees all these medications on his pharmacy-obtained medication list.

And then, oops, there goes Han’s BP in the toilet…

Ideally, your EMR allows you to denote both how medications are prescribed AND how the patient is taking them - in a readily visible manner! However, many EMR programs aren’t quite so friendly and don’t have that capability just yet.

So in the meantime, we have to figure out how to document these difficult scenarios in a way that avoids patient harm.

A key piece of this is communication! Namely, communication between the pharmacy technician and the covering pharmacist, who then needs to decide what and how to escalate issues to the ordering provider.

But also…communication with the patient to clarify identified discrepancies. Oh, and while we're at it, let's include communication with the patient’s PCP, communication with the patient’s nurse for increased monitoring if a medication situation is unclear, and so on. So much communication. #allthecommunication.

Alright, so now here's where we are...

Pharmacy personnel trained in the Jedi ways of interview techniques (and who have filling pharmacy connections) should work to obtain a medication history as soon as possible after admission. AND documentation should identify both how a medication was prescribed as well as how it’s being taken.

Phew. Tall task!

Medication Reconciliation Training

This is why appropriate training is so imperative. Most pharmacy technicians that obtain medication histories undergo training programs.

These programs consist of an initial didactic portion, which includes assessment of drug knowledge via a Top 200 list and/or CPhT (Certified Pharmacy Technician) achievement through the PTCB (Pharmacy Technician Certification Board).

An experiential component follows the didactic portion. This consists of shadowing and then supervised medication history work.

It’s pretty rigorous. But you can see how if we aren’t obtaining an accurate and thorough list on the front end of a hospital admission, errors can be propagated all the way through to a PCP follow up appointment after discharge!

That's IF the patient isn’t readmitted before then for a medication-related issue.

The Future of Medication Reconciliation

Most of this post has focused on the medication history aspect of medication reconciliation for this reason: garbage in, garbage out.

We need to get the best possible medication history from the start, and then the other points of transfer and discharge become easier. (Note: I didn’t say easy, I said easier.)

However, I don’t want to completely minimize the other med rec points of opportunity either. And neither do institutions.

Even in a good situation when patients are knowledgeable about their medications AND a pharmacy-driven review has taken place, there is always the chance that there’s a forgotten bottle sitting at home in a medication cabinet.

In order to combat this, some health systems are experimenting with scheduling "touch points" after the patient is discharged.

This is usually a phone call to the patient within 48 hours of hospital discharge when he is settled at home and has all medication bottles in front of him. However, some places are even trialing home visits by pharmacists!

Discrepancies identified at this point are communicated either back to the discharging provider or the PCP as necessary. Problems with affordability of prescriptions can also be identified, rather than waiting for the next admission or physician appointment. SO much amazing work being done!

[PC]: Addressing financial issues is one of the outpatient pharmacy’s biggest roles during discharge. If you’re an independent, and you’re looking to partner with a local health-system, you will win them over if you can communicate simple coverage issues back to care management or nursing before the patient goes home. Novolog or Humalog? Januvia or Tradjenta, or neither? Questions like that are simple for us to answer but can actually save lives.

How to Do a Med Rec

Hopefully some of the thoughts and questions posed in this post will spur you to consider how pharmacy can impact the process of medication reconciliation.

I don’t necessarily have lots of answers here…but lots of questions (sorry?). But this post needs a summary. Something to tie it all together.

If I had to outline how to do a med rec, here's what I'd do. Please note that this list is intended to include everything about the process - from the top-level "administrative policy" perspective all the way down to what questions to ask during the patient interview. It's impossible to be all-inclusive, but it's my best crack at it.

  1. Develop a patient prioritization scheme and documentation process that works for the specific institution and electronic medical record (EMR).

  2. Train pharmacy personnel on said process.

  3. Communicate with other disciplines that pharmacy is working on medication histories

  4. Identify a patient in need of a medication history.

  5. Speak with the patient’s nurse and/or scan the EMR to identify obvious communication or cognitive barriers.

  6. Do background research on the patient, including obtaining their outpatient pharmacy fill records, medication records in the EMR, insurance claim records, etc...

  7. If possible (i.e., if patient is awake, alert, and oriented), introduce yourself and ask the patient (or family) which pharmacy/pharmacies fill the outpatient scripts.

  8. Use your background research as a baseline, and interview the patient (or family member/caregiver as appropriate) about allergies, reactions, and home medications.

  9. Use open ended questions as much as possible…without dead-ending the conversation. a. Be sure to ask about over the counter medications, herbals, vitamins, supplements, or nontraditional delivery method medications (inhalers, injections, eye drops, creams, weekly/monthly doses).

  10. Clarify any discrepancies between the pharmacy records you obtained and patient’s report. This may require calling additional pharmacies or calling the same pharmacy again. Or it may mean scanning through outpatient visit notes (if available) to see what changes were made during outpatient appointments.

  11. Document all medications in the EMR per your institution's process. a. Include as much of the following information as possible: drug name, strength, dosage form, dose, route, frequency, duration (if applicable), date/time of last dose, and date/quantity of last fill. b. If a patient is prescribed a drug but has self-discontinued that medication, this is a tricky scenario. Each situation is different and requires a decision about whether or not to keep that medication on the list. But regardless, put a note on the list regarding patient’s adherence.

  12. Make sure to use your help chain if you identify urgent issues during the medication history process.

a. A repeat medication reconciliation may be required if your new med list is drastically different than the original one on admission.

b. Barriers to adherence such as cost may also be communicated as appropriate.

13. Follow up on any necessary medication changes based on the new medication history.

Yeahhhh. It’s complex and can spiral quickly with complicated prescribed-but-not-taking scenarios.

Maybe you have some ideas about how to mitigate the difficult situations! Brainstorm, please!

The health care system needs your help – patients like Han need your help – so let’s all put our brains together and keep figuring out medication reconciliation.

Keywords: medication reconciliation, medication safety, meds to beds

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