Protocol 4-833 - General Medications Reconciliation

CMH EMS & MIH Protocols

EMT w/CHW:

• The goal of medication reconciliation is to document an accurate medication list, determine if the patient is following their prescribed medications, and educate the patient through inspection of medications, organization containers, and interview techniques.
• Review pertinent medical history and medical provider's orders.
• Medication will be reviewed and documented on the initial visit after enrollment and periodically updated to include prescriptions, over-the-counter, samples, vitamins, herbals, essential oils, and other supplements.
• Discuss other medication or substance use the patient may not want to disclose.
• Involvement of the patient and their care team should be included considering input from the patient, family, caregivers, medical records, and medications found in the home.
• Record medication name, dose, frequency, route, purpose, and date/time of last dose in the electronic medical record.
• Allergies and adverse reactions should also be updated with each encounter.
• Refer to Policy NUR09-08 - Medication Reconciliation for Expanse instructions on how to complete a medication reconciliation.
• Consider assisting the patient in creating an easy-to-read quick reference in a location that will benefit the patient in taking the correct medications at the right times.
• Consider assisting the patient in sorting medications.
• Educate and stress the importance of medication compliance to the patient.
• Provide education as appropriate on what medications are used for, medication interactions, and possible side effects.
• Facilitate other questions such as alternative medications and other requests by the patient to the PCP. Do not change any medications, change any dose, or advise the patient how to alter their medications without consultation with their PCP.
• If a discrepancy, duplication, or other issue is found during reconciliation, refer changes in medication orders to the patient's PCP. Other changes where a misinterpretation of current orders has occured, provide patient education and corrections.
• In the case where a patient has not been compliant with medications for more than a few days, consult with the PCP about resuming.
• Provide instructions, as appropriate, to the patient on how to dispose of their medications appropriately. Transportation of the patient's medications by MIH should not be done.

AEMT w/CHW:

• Ensure completion of applicable items above.

RN w/CHW:

• Ensure completion of all applicable items above.

Medic w/CHW:

• Ensure completion of all applicable items above.

CP:

• Ensure completion of all applicable items above.

CMH Pre-Hospital Services Mission: "Provide safe, exceptional, and compassionate care to our communities with an emphasis on highly trained and empowered staff."

CMH Mobile Integrated Healthcare Mission: "Provide exceptional, compassionate, and patient-centered care by a mobile collaborative team to improve patient experience, improve quality outcomes, and reduce healthcare costs."

Polk, Hickory, Cedar, & St Clair County EMS Protocols is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.