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Provincial Clinical Documentation Standard Medication Reconciliation
Provincial Clinical Documentation Standard
Medication Reconciliation
Standard Title: Medication Reconciliation
Completion Date: September 25, 2017
Medication Reconciliation Documentation Working
Group:
Medication Reconciliation
Version: 0.7
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Document History Version Date Description of Revision Completed By / Revised By
0.1 2017-04-04 Creation of initial draft (utilizing template) Vanessa Moorgen 0.2 2017-05-16 Edits Core working group 0.3 2017-06-16 Member feedback Working group 0.4 2017-07-10 Final edits Core working group 0.5 2017-08-29 Feedback from Provincial Clinical
Documentation Committee incorporated Core working group
0.6 2017-09-12 Wording change Core working group 0.6 2017-09-12 Wording changes requested by Provincial
Clinical Documentation Committee Core working group
0.7 2017-09-25 Document finalized Adopted/approved by Provincial Clinical Documentation Committee
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Contents Important Information Before You Begin .................................................................................................3
Sponsorship & Accountability ..................................................................................................................4
Working Group Membership ...................................................................................................................4
Background ............................................................................................................................................4
Methods and Key Decision Points ............................................................................................................4
Assumptions ...........................................................................................................................................5
Documentation Definitions, Minimum Data Sets, and Meta Data .............................................................6
Documentation Elements ...................................................................................................................... 11
Methods on reaching consensus: Working group decisions .................................................................... 11
Procedures, Policies & Guidelines .......................................................................................................... 12
Decision Support/Clinical Guidance Recommendations .......................................................................... 12
Preparation for Analytics ....................................................................................................................... 13
Next Steps ............................................................................................................................................ 13
Appendices ........................................................................................................................................... 14
Appendix A: Terms of Reference .................................................................................................................. 14
Appendix B: Medication Reconciliation Documentation Working Group Membership and Governance Structure ....................................................................................................................................................... 15
Appendix C: Direction, Decision-Making & Adoption diagram .................................................................... 17
Appendix D: Documentation Elements ........................................................................................................ 18
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Important Information Before You Begin The recommendations contained in the Provincial Clinical Documentation Standard (which may be referred to as the ‘Standard’ for the rest of this document) have been provincially adjudicated and are based on the available evidence and clinical practice considerations. Clinicians applying these guidelines should, in consultation with the patient and/or family, use independent medical judgment when planning patient-centred care. The Provincial Clinical Documentation Standard is based on standards and requirements outlined by the Health Quality Council Alberta (HQCA), Choosing Wisely Canada campaign, Safer Healthcare Now campaign, and Accreditation Canada Medication Reconciliation Required Organizational Practice. The ‘Standard’ will be reviewed periodically and updated as best practice and evidence change.
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Sponsorship & Accountability Co-Chairs
• Clinical Documentation Lead: Greg Duchscherer • Senior Project Manager, Quality & Healthcare Improvement: Lauren C. Black
Accountability The Medication Reconciliation Documentation Working Group is accountable to:
• Provincial Clinical Documentation Committee • Clinical Operations Executive Committee (COEC)
See Appendix A for the Medication Reconciliation Documentation Working Group Terms of Reference.
Working Group Membership See Appendix B.
Background There is a lack of consistency on how clinicians document medication reconciliation (MedRec) related criteria across Alberta Health Services (AHS). Local zone or program specific tools capture different elements, but no one tool comprehensively addresses all elements. Therefore, there is a need for provincial standardization on documentation practices, which will improve information transfer and reduce risk to the patient. Standardized terminology and documentation elements are essential for the Provincial Clinical Information System development.
Methods and Key Decision Points Methods Early discussions began in July 2016 with core committee members to plan and execute next steps: 1. Completing an inventory of all MedRec related forms from across the Province as well as some
key affiliate groups (Canadian Patient Safety Institute, Safer Healthcare Now, other provinces). 2. Narrowing the inventory list to include only active forms. 3. Completing a data frequency analysis. 4. Drafting a Terms of Reference and Medication Reconciliation Documentation Working Group
membership list (completed December 2016). 5. Convening committee meetings (February 2017) to review and solidify the elements identified
from the preliminary review. Key Decision Points Meetings concluded in March 2017, and the group came to agreement in defining essential documentation elements related to MedRec.
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Assumptions • Provincial standardization for documentation of MedRec is required, regardless of medium. • MedRec documentation will be considered as a continuity of care record element. • The work produced by the MedRec Documentation Working Group will be shared to support
future planning and implementation related to paper documentation and to existing clinical information systems.
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Documentation Definitions, Minimum Data Sets, and Meta Data Table 1: Definitions lists commonly used terms in medication management and/or records management; and statements describing the meaning of the terms.
Functionality and design of the future Provincial Clinical Information System may dictate the final format, wording and flow of criteria as certain functionality may not be flexible and/or may already be a part of the provincial Clinical Information System.
Table 1: Definitions
TERM DEFINITION Best Possible Medication History (BPMH)1
A complete and up-to-date list (electronic or paper) of the patient's current medications that has been verified using at least two sources. Whenever possible, one source should be the patient/family interview. The list includes: - Name of the medication (all prescribed, over-the-counter, herbal, vitamin, homeopathic, health remedies and substances of abuse); - dosage; - route of administration; - frequency of administration; and - time of last dose (as appropriate).
Home Medication All medication (all prescribed, over-the-counter, herbal, vitamin, homeopathic, health remedies and substances of abuse) being taken by a patient prior to entrance in a program. A system tracking term to support knowledge of the medications a patient was previously taking.
MedRec Encounter Describes the point of encounter with the patient MedRec process described as Admission, Transfer or Discharge.
Medication Use Identifies if the patient takes any medication products (all prescribed, over-the-counter, herbal, vitamin, homeopathic health remedies and substances of abuse), does not take any medications or if medication list is unable to be obtained.
Medication Use Sources For those patients taking medications, identifies from what source information was collected
Medication Name Name(s) of identified products used by the patient. These products should include medications (all prescribed, over-the-counter, herbal, vitamin, homeopathic, health remedies products and substances of abuse).
Dose Based on prescription instructions, quantity or amount of the identified product intended to be taken at one time and the unit of measurement, if applicable.
Route Name route of administration by which the identified product enters into the body.
Frequency The number of times an identified product is intended to be taken per time unit, such as "X" time per day, week, month or every "X" hours, days.
Last Dose The date and time when medication was last taken.
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Discrepancy2 A difference identified between what the patient is actually taking versus how the medication was intended to be taken (prescribed)
TERM DEFINITION
Rationale for Medication Order Changes
Reason for changes to a current medication order.
Triplicate Prescription Order
Identification of the medication order details for those medications listed on the Alberta Triplicate Prescription Medication List.
PAPER FORMAT (for use during downtime) Order Processed Indication
Identification on a paper copy of the BPMH form to display the order has been processed at the patient care area and has been forwarded to pharmacy for medication processing.
Number of Pages Identification on the BPMH form to display the number of pages completed. BPMHs may involve numerous pages.
Signatures Availability of lines on the BPMH form for staff signatures and designations of those involved in completing the BPMH documentation; signature lines for authorized prescribers utilizing the BPMH to order medications.
Do Not Thin Identifier to indicate an active BPMH form(s) is not to be thinned from the patient record.
References 1. Alberta Health Services Governance Document Medication Reconciliation Policy (PS-05)
March, 2016. 2. The Electronic Medication Reconciliation Group. (2014). Paper to Electronic MedRec
Implementation Toolkit. ISMP Canada and Canadian Patient Safety Institute.
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Table 2: Minimum Data Sets
Element Fields Valid Response Type of Response Demographics Patient Identification auto-populate
Date stamp
Time stamp
Height Value in centimeters
Weight Value in kilograms (neonates
in grams)
Allergies Confirmation of allergy data on
file with ability to update content.
Medical conditions Confirmation of data on file
with ability to update content.
Encounter* Admission Transfer Discharge
Data dictionary - drop down
* Future consideration for outpatient/ambulatory care type patient visits.
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Element Fields Valid Response Type of Response Medication Use No home
medications
Data dictionary - drop down - one choice
Unable to Obtain, Please Specify:
Data dictionary - drop down - multiple choices plus free text option
Medication Use Sources
Patient medication containers/packaging
Data dictionary - drop down - multiple choices
MAR Medication discharge plan Patient recall Family recall Patient home medication list Netcare PIN Community Pharmacy Name/contact number Prescriber Other: Text field
BPMH Medication Name
Text field or drop down utilizing CIS functionality for product lookup
Dose
Text field Route
Text field or drop down utilizing CIS functionality for product lookup
Frequency
Text field or drop down utilizing CIS functionality for product lookup
Last Dose If Known
Text field. Date/time format.
Discrepancy
Yes Data dictionary - drop down - one choice
Addendum/Comments Drop down options of comment responses plus free text field
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Element Valid Response Type of Response Data Tool Completion / Identification
End User Name
CIS stamp
Designation
CIS stamp
Date
CIS stamp Time
CIS stamp
Medication Ordering
Medication name
BPMH data
Dose
BPMH data Route
BPMH data
Frequency
BPMH data Quantity
Text field
Refills
Text field Medication Order Modification
Order changed Order stopped Order held
Data dictionary - drop down - one choice, if order different than listed in BPMH data.
Rationale for Changes
Drop down list of common responses plus text field
Prescriber Name/Signature
CIS stamp
Date of Medication Order
CIS stamp
Triplicate Prescription Documentation
Text field outlining triplicate prescription order detail.
Patient Transition
Patient Review Yes/No Data dictionary - drop down - one choice
Addendum/comments related to education and documentation provided.
Text field
Primary Prescriber Refills
Yes/No: indicating patient informed to see primary prescriber for prescription refills.
Data dictionary - drop down - one choice
Patient Transition: Next Care Provider
Yes/No Data dictionary - drop down - one choice
Addendum/comments related to documentation provided to next care provider.
Text field
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Documentation Elements Diagram A: Documentation Elements
See Appendix D for a full-size diagram.
Methods on reaching consensus: Working group decisions The ‘1:2:4:all’ facilitation technique was utilized to review the identified MedRec data elements and reach consensus on final elements. This technique involves individual review and reflection (working as “1”), then discussion in groups of two (“2”). Then two groups of 2 merge to review key observations in a group of four (“4”). A summary of comments is then provided to the full group (“all”). This approach allows for individual comments to be captured while using the iterative approach to synthesize similar observations in an efficient manner. The full membership then reviewed all recommendations and allowed for further discussion. Some elements were identified to be explored in more detail with process development at a later time.
When the group had completed its first ‘1:2:4:all’ process, feedback reflected that working in groups of 2 (“2”) did not provide additional benefit. The group decided to delete the step involving groups of 2, continue with a ‘1:4:all’ format for future small group work.
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Procedures, Policies & Guidelines The AHS Provincial MedRec Policy (PS-05) has been in place since May 1, 2012, with subsequent revisions in 2015 and 2016. The next review date is December 2017. Future revisions to the policy or the creation of necessary governance documents will be assessed once vendor functionality is confirmed.
Decision Support/Clinical Guidance Recommendations 1. When a medication is added, changed or discontinued, the provincial Clinical Information
System will automatically check the new information against existing orders. a. The provincial Clinical Information System will visually prompt users that a medication has
been added, changed or discontinued. b. Automatic checks will occur between existing information and new orders.
2. Users will be prompted to enter patients’ medications as taken at home prior to prescribing any medications. These medications can be amended at any point.
3. All medications will be clearly categorized as taken prior to admission, active/current, or discontinued, etc. Users will be prompted to verify medications at all transition points.
4. Users will be required to choose between: “No medications”, “Unable to obtain” or “Begin collecting the BPMH”.
5. It is recommended that guidance is enabled to: a. Automatically and electronically generate and indicate in real-time, alerts at the point of care
for drug-drug, drug-adverse reaction, substance-adverse reaction contraindications based on medication list (MedRec), medication adverse reaction list, and computerized provider order entry [CPOE] (Meaningful Use Standards and Certification Criteria/42 CFR 495.6 [MUSCC]);
b. Provide certain users with the ability to adjust notifications provided for drug-drug and drug-allergy interaction checks (Meaningful Use Standards and Certification Criteria/42 CFR 495.6 [MUSCC]), and;
c. Enable a user to electronically record, modify, and retrieve a patient’s active medication adverse reaction list as well as medication adverse reaction history for longitudinal care (Meaningful Use Standards and Certification Criteria/42 CFR 495.6 [MUSCC]).
6. The provincial clinical information system needs to: a. Include date/time stamp as well as user identification for all encounters particularly
additions, changes and discontinuations of any medications. 7. Users will be prompted to initiate MedRec in alignment with anticipated date of discharge
processes.
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Preparation for Analytics Outcomes related to MedRec documentation will need to be confirmed once the CIS vendor and functionality are confirmed and data collection capabilities are identified.
Next Steps 1. AHS Policy to review applicable content 2. Medication Reconciliation Documentation Working Group to develop initial draft of the
recommendations and circulate to membership for review and sub-consultation in their respective departments.
3. Submit latest draft of recommendations to the Provincial Clinical Documentation Committee at June 20, 2017 meeting.
4. Feedback received from Provincial Clinical Documentation Committee (August 15, 2017) to be incorporated into the draft. Revised document to be returned to committee for final review.
5. Approved Recommendations document will be kept on file until needed after the provincial Clinical Information System is selected and then reviewed against CIS functionality for MedRec.
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Appendixes
Appendix A: Terms of Reference
Medication Reconciliation Documentation Working Group Terms of Reference Purpose: The Medication Reconciliation (MedRec) Documentation Working Group will collaborate in the development of Provincial standards for essential aspects of medication reconciliation documentation. Chair(s): • Greg Duchscherer, Clinical Documentation Lead, Clinical Knowledge and Content Management, Chief Medical
Information Office (CMIO) • Lauren Black, Senior Project Manager, Performance Improvement, Quality and Healthcare Improvement Governance: The MedRec Documentation Working Group is accountable to the Provincial Clinical Documentation Committee. See Appendix B. Objectives: The MedRec Documentation Working Group will: • Establish minimum standards for the documentation of medication reconciliation. • Determine consistent terminology. • Identify appropriate stakeholders and collaborate for input and feedback.
Meeting Frequency: The working group will meet bi-weekly or at the call of the chair(s).
Agenda/Minutes: An agenda will be established for each meeting and will be maintained and distributed by the chair or designate. Minutes will be circulated to the committee membership and to the ad hoc members as appropriate. SharePoint will be utilized for document access and retention. Responsibilities of Chair(s): • Set agenda and lead meetings • Establish timelines and prioritize work to be completed • Support open and constructive participation among working group members • Report to CMIO, as required
Responsibilities of Members: • Participate fully in working group meetings • Identify and appropriately prepare an alternate to attend meetings in the member’s absence • Provide any feedback required in a timely manner, respecting deadlines • Review meeting minutes and associated documents prior to meetings • Connect with stakeholders in your zone, sites, and/or departments to relay information or seek feedback • Ensure chair receives notice of any changes in membership and contact information
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Appendix B: Medication Reconciliation Documentation Working Group Membership and Governance Structure
Medication Reconciliation Documentation Working Group Membership
Name Title Representative For Zone
Greg Duchscherer Clinical Documentation Lead Provincial CKCM Provincial
Dawn McDonald Medication Safety Pharmacist Provincial MedRec Provincial
Lauren Black Senior Project Manager Provincial MedRec Provincial
Doug Pankoski Clinical Informatics Lead Provincial CKCM Provincial
Kelly Halseth Director Forms Strategy & Management
Provincial
Troy Lohnes Manager Pharmacy Informatics and Technology
Provincial
Carol Robertson Senior Consultant, Ambulatory Care Optimization
MedRec CancerControl Alberta
CancerControl Alberta
Gisela Mullan Clinical Quality Improvement Consultant
MedRec Corrections Provincial
Beth Wilkey Director - Policy Practice, Access and Case Management, Provincial Continuing Care
MedRec Continuing Care Provincial
Josie Puhov Medication Reconciliation Coordinator, Clinical Education
MedRec North Zone North
Lynn Whitten Program Manager,
Safe Clinical Practice Program
MedRec Calgary Zone Calgary
Ken Wou Medication Quality Consultant MedRec South Zone South
Susan Rasmussen Patient Safety Consultant, Medication Reconciliation
MedRec Central Zone Central
Kinnson Lo Medication Management & Medication Reconciliation
MedRec Covenant Health Covenant Health
Vanessa Moorgen Senior Medication Management Consultant
MedRec Edmonton Edmonton
Sandra K. Young Advisor Accreditation Provincial
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Dr. Echo Enns Hospitalist Physician Calgary
Paula Matthes Team Lead, SCM Configuration and Development, IT – Technology Services
Sunrise Clinical Management (Ad hoc)
Calgary
Lisa Letendre NZ Senior Advisor - Clinical User Support, Information Technology
Meditech (Ad hoc) Provincial
Michelle Christensen
Configuration Lead, eClinician EMR
eClinician (Ad hoc) Edmonton
Jennifer Wheaton Manager of Quality & Patient Safety (Edmonton), EMS Operations
EMS (Ad hoc) Provincial
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Appendix C: Direction, Decision-Making & Adoption diagram
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Appendix D: Documentation Elements