Medication reconciliation is a process of ensuring that the patient’s medication is accurate and consistent in all the stages of care to prevent medication errors.
When the patient is going to get admitted in the ward ,he or she need to be assessed initially by the doctor and initial assessment will be filled, where the past medications ,the patient has been taking wil be reconcilled in the Medication Reconciliation form.
While reconciling it is important to look after the old prescription of the patient or the medication they have rather than just entering the drugs when some patient say orally.
Here is a scenario, where the person who reconcile the patient and wrote the drugs based on what the name patient says, without verifying . As a clinical pharmacist while cross verifying ,the drugs the patient actually takes was different from what she had told.
She was not taking Metaprolol but she was very confident while saying the drugs list .
And she was taking a drug (combination of Pregabalin and Nortriptyline), but she mentioned it as Renerve plus . Due to this documentation error , the drugs was continued in the drugs chart and a dose was given , then it finally resolved and further cosequences was prevented.
Even past drug allergy need to be verified and entered throughout the case file.
This is why documentation is very important in healthcare. Every details in the case file is important, everything needs to be filled properly .
MBH/PS