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 p