Patients are commonly discharged from acute rehabilitation units with many more medications than they were admitted with. This is an excellent opportunity for pharmacists to perform medication reconcilliation.
It is not uncommon for a patient, following an extensive surgery, to be transferred to an acute recovery unit for their rehabilitation. For instance, when an elderly patient undergoes a hip replacement surgery, it may not be a good idea to send them directly home following the immediate hospital recovery period.
This particular individual may have coexisting disease states, such as diabetes or high blood pressure, that need special attention while they are recovering for 3 or 4 weeks. In addition, the patient may have been started on a blood thinner or a course of antibiotics.
While in the rehabilitation unit, this patient has multiple medication orders on their chart. These orders include all of the patients previously ordered at-home medications, as well as any new medications ordered to treat the current condition. Regularly, these patients are started on a host of vitamin supplements for any dietary deficiencies and to boost their recovery. Additionally, a multitude of ‘as-needed’ orders may cover 3 or 4 different ways to treat pain, nausea and/or vomiting, and constipation.
Our patient has now been in the acute rehabilitation unit for 3 or 4 weeks and is ready to be discharged back to home. In an effort to maintain continuity of care, the hospitalist working in the recovery unit reviews the list of medications the patient has been on, and electronically sends all of these orders to the patients' pharmacy of choice.
Now, prior to leaving the facility, the nurse will come into the patients' room to discuss all of the discharge orders. To facilitate this discussion, as well as meet regulatory requirements, all of the discharge instructions and consumer medication information are printed out for the patient to take home.
I have seen patients show up to our out-patient pharmacy with discharge instruction packets of greater than 75 pages. Upon discussion with the patient, we dig into the pages and find the medication administration instructions tucked deep inside the packet. Usually, the discharge medication instruction sheets take up nearly 10 pages. After seeing many of these patients come through our clinic, it is my opinion that even a seasoned health care professional would have a difficult time managing their medications based on this enormous discharge instruction packet.
This process provides an excellent opportunity for pharmacist intervention. In our clinic pharmacy, it is our goal to send patients out with all of the discharge medication instructions consolidated down to a single page Patient Medication Record (PMR). We like to take this opportunity to perform medication reconciliation, assuring that there are no discrepancies between the discharge medication instruction sheet and the prescriptions we are filling for them to pick up and take home.
While at the pharmacy counseling counter with the patient, we describe how we are going to create a PMR for them to use when they are at home. We will briefly recreate the scenario in which they were handed a stack of papers prior to discharge, understanding that this process may have felt a bit overwhelming for them. We will then discuss a plan for taking all of that information about medication dosing and putting it onto a single piece of paper.
In our pharmacy, we have added a section on our prescription label design to accommodate extra information. We have one sticker that lists the prescription number, name of the medication and directions. This sticker is used on our PMR; however, it would also be reasonable to write the information in on the record if a sticker is not available.
More than a year ago, I wrote an article describing our PMR sheet that we use in our store. The article includes a copy of the work sheet for download. Please visit this link and download the form. You will be amazed at the joy patients share when they realize all of their medication instructions will fit on one single page.
Keep it simple in 2018. Happy New Year!