Document Medication Reconciliation

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Updated: 07/10/2023 | Views: 2940

Medication reconciliation is a formal process of obtaining and verifying a patient’s active medications. After confirming the Active Medications list is accurate and up to date, a medication reconciliation can be performed through a clinical note or the patient's medication list. To help providers meet MIPS measures, the medication reconciliation must be performed through the clinical note on the same day of the visit.

Perform in Clinical Note Providers must perform a Medication Reconciliation for new patients, patients with a transition of care, or a referral. On the Dashboard, click on the appointment. The Appointment Card opens. Click Create Clinical Note. The default note type opens.
Click to select "Receiving". The Message pop-up window opens. Click Ok to confirm. The pop-up window closes and another Message pop-up window opens. Click the appropriate response. The pop-up window closes.
Click the Medication section. The Medications pop-up window opens. Select Performed or Excepted - Medical Contraindication from the Medication reconciliation drop-down. The name of the user who performed the medication reconciliation, and date and time it was last updated displays. Click Close when finished. Click the refresh icon to update Medication section with the name of the user who performed the medication reconciliation, and date and time it was last updated displays. Continue with patient care and sign the note when finished.
Perform in Medication List Enter the first 2–3 letters of the patient's name or date of birth (mm/dd/yyyy) in the top navigation bar search box. Click to select the patient from the auto-populated results. The patient's Facesheet page opens. Click Medications. The Active Medications page opens. Select Performed or Excepted - Medical Contraindication from the Medication reconciliation drop-down. The name of the user who performed the medication reconciliation, and date and time it was last updated displays.