Step 1: The first part of an accurate medication reconciliation is to see what medications the patient is prescribed as an outpatient. Outpatient medications can be viewed by going to the "Meds" tab of the patient's chart and looking at the bottom-most section labeled "Outpatient Meds." Here medications are listed as "Active," "Active/Susp" (indicating they have been sent but not yet filled by the patient), "Expired" (meaning the refills on this medication have run out - either purposefully or not purposefully), and "Discontinued." This should have been looked through and confirmed during the admission process. 

• The section above "Outpatient Meds," labeled "Non-VA Meds" are medications filled by non-VA providers that have been entered into the system by the patient's VA provider. These may or may not be accurate and need to be reviewed with the patient. 

• Often, medications prescribed in the ED will populate in the "Outpatient Meds" section. These are one time orders and will be at the top of the list. Make sure to discontinue these. 

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*Also, please note your team pharmacist can work with you to make sure the patient has all the refills and appropriate meds with discharge: let them know about 24 hours before discharge so they can start working on it. 

 

Step 2: Prescribe any new medications you may want to discharge the patient with. This can be done by going to the "Orders" tab and clicking “Add new order” >> “Outpatient Medications” >> type the medication name, # of pills needed, if refills are needed. 

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• ​Click on “Window” to have the medication sent to Outpatient pharmacy. If you need the medication to be filled ASAP, call the outpatient pharmacy at x58235. 

• Let the nurse know so they can call pharmacy to make sure the medications are handed to the patient prior to discharge.

• Note: if you are prescribing narcotics, you must complete a paper prescription.  Controlled substance prescriptions can be obtained from the chief resident’s office. You must use your VA DEA number, which can be obtained by calling the outpatient pharmacy.

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Step 3: Create the note - Discharge Instructions, Part B. This will pull all the medications in the "Outpatient Meds" list that are "Active," "Active/Susp," and "Pending," including all of the new medications you ordered. It will pull the medications in alphabetical order and includes medical supplies. We ask you to rearrange the list in a way that would be common sense for the patient as this is the list they go home with. i.e. For your COPD: Albuterol, Symbicort. For your coronary artery disease: Aspirin, Atorvastatin. 

• There is also a section for a description of what happened to the patient during their hospitalization. Please write a few sentences in non-medical jargon for the patient. 

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