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An accurate medication history for hospital patients is the product of teamwork shared by pharmacists, physicians, and nurses. The pharmacist must champion this process for it to work smoothly.
Gathering an accurate medication history for hospital patients is definitely a team effort shared by pharmacists, physicians, and nurses. To be successful, somebody has to take ownership of the process to monitor the medication reconciliation. The pharmacist must champion this process for it to work smoothly.
Hospitalists, attending physicians, medical residents, and interns all recognize how important it is to collect an accurate medication history and ensure precise medication reconciliation.
Hospitals should develop a clearly defined workflow for pharmacists and physicians to obtain and reconcile medication histories. Medication reconciliation, effectively conducted, will provide an accurate discharge medication list.
The electronic medical record system will maintain the medication histories; if patients are readmitted, this information will be readily available to the emergency department. However, the record must be reviewed and updated by clinicians.
The pharmacist in the community setting, whether it be in a chain store, an independent pharmacy, a big-box operation, a supermarket, or a hospital ambulatory care apothecary, will become involved in this process as well.
The hospital’s clinical pharmacist may rely on the community pharmacist for an accurate and updated list of the medications currently prescribed to the patient. In most cases, the primary care physician has an accurate record of the patient’s medications and will provide the patient with a printout, using the NextGen program. It is imperative for the patient to carry this list with him or her at all times - especially when being treated by a specialist or an emergency department clinician.
It is then up to the attending physician to determine which home medications the inpatient will continue taking while admitted, and which, if any, should be changed upon discharge.
There are three major categories of medications that an inpatient can be prescribed during the admission process.
The attending physician or hospitalist will then determine which of these medications should continue and which should be stopped while the patient is a hospital inpatient. If intravenous metoprolol is prescribed, the physician might want to discontinue the patient’s PO carvedilol to prevent duplication of therapy. PO OxyContin and all combinations may be discontinued while the patient is being given IV morphine following a surgical procedure.
When pharmacists, retail or hospital, work in tandem with medical residents in a community teaching hospital, the collaboration should lead to a reduction in readmissions, emergency department visits, and hospital costs.
Complete and accurate medication reconciliation by the entire healthcare team will increase overall accuracy of the admission process.