Reconciling Inpatient Medications

State the transition type explicitly in all output.

A2. Gather Available Medication Lists

Required sources (mark [UNAVAILABLE] if absent — never silently omit):

• BPMH: Patient/caregiver interview, community pharmacy records, PCP med list, prior discharge summaries, pill bottles/med cards
• Active MAR: Current medication administration record from EHR
• Admission/Transfer/Discharge orders: The target order set for the transition
• Allergy and adverse reaction list: Including severity and reaction type
• Relevant labs: Renal function (CrCl/eGFR), hepatic function (LFTs), INR/anti-Xa, drug levels, A1c, electrolytes

A3. Assess Patient Complexity

Flag any of the following — each increases reconciliation error probability:

• Polypharmacy (10+ medications)
• High-risk medication classes present (see below)
• Renal or hepatic impairment requiring dose adjustment
• Multiple prescribers / care teams
• Cognitive impairment or limited health literacy
• Recent ICU stay
• Substance use history affecting medication selection
• Non-formulary medications on home list

High-risk medication classes (require line-by-line verification):

Workflow

Step 1: Normalize Medication Data

For every medication on every source list, capture these seven fields. Missing fields get [VERIFY].

Step 2: Cross-Reference and Match

Align medications across source and target lists. For each medication, assign one disposition:

Step 3: Transition-Specific Checks

Admission (Home → Inpatient)

• Compare every BPMH medication against admission orders
• Flag chronic medications not ordered on admission (unintentional omission vs. intentional hold)
• Verify home PRN medications are addressed — do not silently drop
• Check for therapeutic substitutions and confirm equivalent dosing
• Confirm allergy list matches home records
• Flag OTC medications, supplements, and herbals that may interact

Transfer (Unit → Unit)

• Map all IV continuous infusions to floor-appropriate equivalents (e.g., IV diltiazem drip → PO diltiazem ER)
• Recalculate renal-dose adjustments if function has changed since admission
• Verify ICU-specific medications are appropriately discontinued (e.g., propofol, vasopressors)
• Confirm stress ulcer prophylaxis is reassessed (discontinue if no longer indicated)
• Check VTE prophylaxis transitions (e.g., heparin drip → enoxaparin)

Discharge (Inpatient → Home/Facility)

• Every pre-admission medication must have an explicit disposition: continued, modified, held (with restart plan), or discontinued (with reason)
• All new medications started during stay must appear on discharge Rx with indication and duration
• Held medications: document whether to restart, when, and at what dose
• Verify discharge doses account for any inpatient adjustments (e.g., uptitrated beta-blocker)
• Confirm no inpatient-only medications are sent home (e.g., IV antibiotics without OPAT plan, heparin SQ prophylactic dose)
• Cross-check discharge Rx against active MAR at time of discharge

Step 4: Generate Discrepancy Report

For every discrepancy found, document:

Step 5: Compile Reconciled Medication List

Produce the final reconciled list using the template in references/INPATIENT-MED-REC-TEMPLATE.md. Every medication on the final list must have all seven fields populated. No [VERIFY] tags may remain in the final output — unresolved items must be escalated.

Output Templates

Reconciliation Summary Header

MEDICATION RECONCILIATION — [TRANSITION TYPE]
Patient: [ID/Name]       Date: [YYYY-MM-DD]
Transition: [Admission / Transfer (from → to) / Discharge]
Total Source Medications: [N]    Total Target Medications: [N]
Discrepancies Found: [N]  (Critical: [N] | Major: [N] | Minor: [N])
High-Risk Classes Present: [list]
Reconciler: [Name/Role]    Verifier: [Name/Role]

I-PASS Integration for Handoff

When reconciliation accompanies a handoff, structure the medication summary using I-PASS:

Checkpoint B: Post-Draft Alignment (Mandatory)

After generating the reconciled list, verify every item below. Do not finalize until all pass.

• Every source medication has an explicit disposition (no medication silently dropped)
• Every high-risk medication class present has been individually verified
• All discrepancies are categorized by severity and have a recommended action
• Held medications include a restart plan or explicit discontinuation rationale
• New medications include indication and intended duration
• Therapeutic substitutions include dose-equivalence confirmation
• Allergy/adverse reaction list is consistent across all sources
• Route and frequency are clinically appropriate for the care setting (no IV meds on a floor discharge, no TID dosing for a once-daily drug)
• Output uses standardized terminology — no abbreviations on the Joint Commission "Do Not Use" list
• All [VERIFY] tags resolved or escalated to human review

Quality Audit

Compliance Anchors

Error-Prevention Checklist

Known Limitations

• This skill does not replace pharmacist clinical judgment — all critical discrepancies require human verification
• Drug interaction screening depends on completeness of the medication list provided
• OTC, supplement, and herbal product history is frequently incomplete — flag this gap explicitly
• Dose equivalence for therapeutic substitutions should be confirmed against current formulary references
• This skill does not calculate renal/hepatic dose adjustments — it flags the need for them

When to Escalate to Human Review

• Any critical-severity discrepancy
• Patient on 3+ high-risk medication classes simultaneously
• Conflicting information between sources that cannot be resolved from available data
• Medication identified that the agent has low confidence in (unfamiliar drug, unusual dose)
• Any controlled substance discrepancy

Guidelines

• Always verify high-alert medications (anticoagulants, insulin, opioids, immunosuppressants, antiarrhythmics) individually at every transition point — never batch-reconcile these classes with lower-risk medications.
• Formulary substitutions must include documented dose-equivalence rationale. When substituting therapeutic equivalents (e.g., home atorvastatin → hospital rosuvastatin), record the conversion basis and alert the patient to the temporary change.
• Discharge medication lists must be finalized and reconciled within 2 hours of the discharge order. Delays beyond this window increase the risk of the patient leaving with an outdated or incomplete medication list.
• Held medications require an explicit restart plan at discharge — including the restart date, dose, and any monitoring required. A medication marked "held" without a disposition at discharge is a reconciliation failure.
• For patients on 3+ controlled substances, perform an independent verification against the state Prescription Drug Monitoring Program (PDMP) database before finalizing the discharge medication list.
• Every reconciliation must be performed or verified by a licensed pharmacist or credentialed provider. AI-generated reconciliation output is a draft tool, not a final clinical document, until human attestation is completed.
• When conflicting information exists between the patient-reported medication history and pharmacy records, document both versions and escalate to the prescribing provider for resolution rather than choosing one source over the other.
• Non-formulary home medications that cannot be therapeutically substituted must be flagged for the discharge planning team at least 24 hours before anticipated discharge to ensure prescription coverage and pharmacy availability.