Discharge Med Rec

What is an Disposition Medication Reconciliation?

The Dispo medication reconciliation (Med Rec) is the process used to communicate to the patient and follow up providers which medications a patient needs to take after discharge from the CDU. The document includes information on medications that are going to be stopped or changed from their previous home medications list, it also includes any new medications to be started at dispo and any medications that are unchanged.

An admit med rec is needed before a dispo med rec can be done. If an admission med rec has not yet been done, you will need to either do one yourself or have the ED pharmacist do one before the patient can be discharged.

Depending on the complexity of the patient, a Dispo Med Rec usually takes about 2 minutes.

Which Patients need a Dispo Med Rec?

A DC med rec is required for any patient that meets any of the following criteria:

A patient going to any facility. This includes rehab, SNF, Long term care, memory care etc.
Any patient for whom a change is being made to one of their home medications (including holding a home medication after discharge)

But Nobody did an Admit Med Rec!

That sucks. The DC med rec just got three times harder, because now you have to do the Admit med rec too. You just can't do a DC med rec until the Admit Med Rec is done. Your colleague let you down. Please let me know so I can give them that feedback, or better yet, tell them yourself. That said, if someone else didn't do it, it still needs to be done. In my mind, the DC med rec is the area of most risk and highest need for quality improvement in the CDU. For any of the patients listed above, a DC Med Rec is absolutely not optional.

When should I do the Dispo Med Rec?

Do the dispo med rec when you are ready to actually discharge the patient. If you do it too early, then additional medications may be given to the patient while in the hospital, which would cause you to need to redo the med rec. I usually do the Dispo Med Rec right before I write the dispo note, as the note will pull information from the dispo med rec into the DC Summary. If you write the note first, and then complete the med rec, you will have to addend the note and hit refresh to pull the info into the note. You can do some of this work ahead of time and pend it, more below.

Can the Pharmacist do a DC Medication Reconciliation?

No. Sorry. This is not a clerical task of just writing down medications, this is a prescribing and MDM task that is not in the pervue of pharmacy. That said, I'm sure they can answer questions about medications if they come up during the process.

How To Do A Discharge Medication Reconciliation

Open the Dispo Med Rec Tool in Epic

From the Dispo Tab, click on the sub-tab called "Discharge Rec".

Notice there are three columns. On the left is the patients home medications prior to their ED Obs stay. The accuracy of this column is only as good as the Admit Med Rec, which is why an Admit Med Rec must be done before you can do a DC Med Rec. In the middle column are all of the medications that the patient is being given while in ED Obs. Finally on the right, is the list of all medications the patient will take when they are discharged, including any changes to home medications, and any new prescriptions.

Continue, Change or Stop Home Medications

Starting in the left hand "Home Medications" Column, review medication listed for the patient prior to this hospitalization. For any medications you wish to have the patient continue unchanged, click the small right arrow (A). For any medications that you would like the patient to continue but at a changed dose or frequency, click the small pencil (B). For any medicaitons you would like the patient to stop after discharge, click the small x (C)

Decide if any inpatient medications should be prescribed outpatient

In the middle column you will need to choose to either stop or write a new prescription for any medication that was given in the hospital that was not already on their home medication list. Most of these you will discontinue by clicking the circle slash (A).

If there is a medication you are giving in the hospital, and would like the patient to continue taking at home, you can use the plus sign (B) to open a prescription for this medication. This does not work if the medication being given in the hospital is IV and you want to write for PO. In that case you will just need to write a new Rx.

You do need to make a decision about every medication. Even if it seems dumb (3 ml normal saline flush, I'm looking at you).

Write new prescriptions and Review the instructions that will go to the patient or facility

Finally in the right hand column, you can see a sub-section for medications to be continued, changed and stopped at home, as well as new medications to be started at discharge. This is your chance to write a new prescription (A).

Once you are done, review it one last time, and sign your work (B). This will send new Rxs to the pharmacy as well.

If you did this work early, and you are not yet ready to sign it, you can Save and Pend (C) your work for you or a future physician to eventually sign.

Congrats! You've done a DC Med Rec

But wait! There's More! The DC Med Rec will auto-populate into the Discharge Note.

If you open the Discharge note before the Med Rec has been done, the note will show "UNREVIEWED MEDICATIONS" in the Discharge medication list.

If the DC Med is Done before you open your Discharge Note, or if you refresh your discharge note after the DC Med Rec is done. Notice how the med list makes it very clear which meds are to be continued, stopped, changed or are new prescriptions.

Last Thoughts

This is the document that a SNF or LTC facility will use to give medications to a patient on arrival, so it is critical that we get this right. While it's ultimately our responsibility to do this well, If you're not sure about a medication, its totally appropriate to ask pharmacy or even IM to help with a medication list.

You all are the highest functioning group of ED docs I've ever encountered. You all can do this, thanks!

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