Start Admission Medication Reconciliation in Profile

article overview & feature requirements this article is part of the medication management workflow in profile you are currently viewing part 1 of the workflow start admission medication reconciliation in profile ← you are here docid\ efzr4polc23wywhlc6woqsubmit or sign the admission reconciliation record in profile docid\ ap4azbx8csbjwhvuqxozyreview the medchart for a patient in profile docid\ abzjd iwqxzfneby0k5vpcreate and manage medication orders from the medchart view in profile docid\ d0sjnlmfrfa8bq7eeefn0create and view new medication orders or new ad hoc medication orders from the medchart view in profile docid\ l7lxss8mxmf9dpioxx 5jdocument medication administration using careflow in profile docid\ w6jiu64bfxdfo5rvunhmz this article is written for clinical users, and provides a step by step walkthrough for launching the admission medication reconciliation feature, creating a new record, and assessing medications for inpatient use topics covered in this article step 1 launch the admission medication reconciliation feature in profile docid\ efzr4polc23wywhlc6woqstep 2 start a new admission reconciliation record docid\ efzr4polc23wywhlc6woqstep 3 assess medication for in patient medication treatment docid\ efzr4polc23wywhlc6woqstep 4 complete the validation and assessment of the entire medication list docid\ efzr4polc23wywhlc6woqstep 5 save (as a draft) docid\ efzr4polc23wywhlc6woq for instructions on finalising and submitting the record, see part 2 of the workflow how to submit or sign the admission reconciliation record in profile docid\ ap4azbx8csbjwhvuqxozy feature requirements profile version 9 0 9 and above self hosted customers will need iis and http set up please contact intrahealth for more information admission reconciliation is a feature of the medchart liscensed module for inpatient medication management please contact the intrahealth support team at help\@intrahealth com to enable medchart step 1 launch the admission medication reconciliation feature in profile go to clinical / medical record search for and select the relevant patient click on med reconciliation in the left hand navigation of the patient's medical record the patient's admission reconciliation list will open automatically a table will be displayed, and the columns will be populated based on any records created and their status note by default, there will be no records for newly admitted patients for re admitted patients, where a medication reconciliation was previously completed, historical records will be available for a patient with an in progress admission reconciliation, the in progress record will be visible for additional detail around the functionality, interpretation, and role action logic around the patient's medication reconciliation list please read "table 1" docid\ x5ygt7otdwhuqpq2rdhab and "table 2" docid\ x5ygt7otdwhuqpq2rdhab in the technical reference guide profile's admission medication reconciliation feature article step 2 start a new admission reconciliation record create a new record click on the create new button to create a new record it's important to note that this buttons is disabled if there are any admission records currently in progress a new modal will launch prompting you to create the 'shell' for the new record enter a unique record name this is required it is important to note that a default name will be displayed with \<patient name> \<current date> this is a mandatory field all characters are allowed must be a minimum of two characters; maximum characters are 250 must be a unique description from any existing active records created if the description made already exists, the following validation error message will be displayed 'record with that name already exists please use a unique one ' there is an option to load initial medication list from the drop down with the same name it's important to note that this is not a mandatory field the usual scripts option takes the medications from the usual scripts list from profile's script feature not making a selection from this drop down is also possible however, if no option is selected (at this time), it cannot be loaded after the fact once all of the fields in the modal are completed, click on the create button this will launch you into the admission reconciliation record where the workflow begins add a medication list to the admission reconciliation record now that you have created the blank new record, you can begin adding or editing the medication list it is important to note that if no medications were pre loaded (see "step 4c" in the "creating a new record" docid\ efzr4polc23wywhlc6woq section above) you can start adding medications one by one all medications added to the medication list will appear in the left hand panel of the screen medications from this list that have not been validated and assessed will be considered incomplete this means that a care team member has not captured all of the required information to validate the medication and/or assess if the medication needs to be part of inpatient treatment at anytime, if you can remove a medication from the list, you can click on the delete icon next to the medication, as shown in the image below click on the add medication button choose either the add formulary or the ad hoc options adding medication from the formulary when adding medication from the formulary, you will be prompted to select a commercially available strength medication enter the medication in the search field three characters must be entered for the search to return any results you will notice that the search will be presented in the left hand view the right hand view will display the highlighted or selected medication, as well as the following selected medication name, strength, and form the generic equivalent a list of available templated instructions (recorded in the formulary) it is important to note that this list may include none an add new button that allows you to enter a new set of instructions from scratch choose if you wish to enter a new set of instructions click on the add new button a new modal will open, and will prompt you to enter the new instructions to be recorded for the selected medication the new instructions will not be recorded in the formulary the new instructions will include fields listed in "table 3" docid\ x5ygt7otdwhuqpq2rdhab found in the technical reference guide profile's admission medication reconciliation feature click ok when all of the mandatory fields have been entered, or click cancel , which will take you back to the formulary screen select a templated instruction provided a checkmark will be displayed beside the selected instruction click ok and the medication and instructions will be added to the admission reconciliation medication list note for additional details around the functionality of the formulary new instruction fields, please read "table 3" docid\ x5ygt7otdwhuqpq2rdhab in the technical reference guide profile's admission medication reconciliation feature article add an ad hoc medication when adding an ad hoc medication from the formulary, a modal will be displayed for you to enter the non formulary medication the modal will include the same fields as above, including the field for what was prescribed for more details see "table 3" docid\ x5ygt7otdwhuqpq2rdhab in our technical reference guide profile's admission medication reconciliation feature article capturing historical information for patient's medication list part of the medication reconciliation workflow consists of obtaining or validating historical information regarding each medication itemised in the list the validation section will include the fields listed in "table 4" docid\ x5ygt7otdwhuqpq2rdhab from the technical reference guide profile's admission medication reconciliation feature article note all fields are optional except the current state field, and the if taken differently, please specify field (if the taking with modified instructions option is selected in the current state field ) click on the started drop down list and select the appropriate date, and or tick the approx date? checkbox if only the approx date? checkbox is ticked, then the approx date? option will appear as a selection click on the last ordered drop down list and select the appropriate date click on the validation provided by field and select the appropriate option enter relevant information in the ordered by free text field select the appropriate option from the current state drop down list tick the with med container? checkbox if relevant note that this checkbox is disabled if the unable to verify option is selected click on the last taken at drop drop down list and select the relevant date you can also tick the approx date? checkbox, or simply tick the checkbox as a standalone if the taking with modified instructions option was selected in the current state field, enter in the relevant inforamtion in the if taken differently, please specify , free text field enter in any notes in the free text notes field step 3 assess medication for in patient medication treatment click on the medication plan drop down list and select one of the options provided in the drop down list option name logic continue on medchart as recorded this option is selected if the patient is to continue taking the medication exactly how it has been entered in the validation section continue with modification this option is selected if the patient is to continue the medication but the directions need to be modified slightly (i e dose increased from 1 tablet to 2 tablet) discontinue this option is to be selected if the medication is not required to be continued as part of the inpatient treatment replace medication from formulary this option is to be selected if the patient is to continue medication therapy but doctor wants to do a therapeutic substitution and switch to a medication from the formulary replace medication from ad hoc this option is to be selected if the patient is to continue medication therapy but doctor wants to do a therapeutic substitution w/ a non formulary medication step 4 complete the validation and assessment of the entire medication list as each medication item gets reviewed, validated and assessed, the information on the left hand panel will reflect the changes made you will notice the left hand side is grouped into four sections based on the assessment status incomplete continue discontinue new this is a good view to review the completion of the list note for more details on the logic around each status please read the "completing the validation and assessment of the entire medication list" docid\ x5ygt7otdwhuqpq2rdhab section found in our technical reference guide profile's admission medication reconciliation feature article delete a medication click the delete icon click the remove or cancel button in the verification message to complete the process step 5 save (as a draft) users can save the current state of the admission reconciliation record it is important to note that a record can only be saved by a user with the appropriate role action see the "set up role actions" https //intrahealth freshdesk com/a/solutions/articles/6000274579?lang=en#setup role actions text=and%20setup%20process ,setup%20role%20actions, a%20new%20role section of the how to configure and setup the admission medication reconciliation feature in profile article saving the record assumes it is not ready to submit for review or approval (refer to the how to submit or sign the admission reconciliation record in profile docid\ ap4azbx8csbjwhvuqxozy ) click the save button at the bottom of the page to save the current state of the admission reconciliation record note if the system is unable to save, an error will be displayed what's next the next steps in the workflow around submitting or signing the admission reconciliation record can be read in submit or sign the admission reconciliation record in profile docid\ ap4azbx8csbjwhvuqxozy learn more for more information on profile's inpatient admission reconciliation featureplease click on the article links below submit or sign the admission reconciliation record in profile docid\ ap4azbx8csbjwhvuqxozytechnical reference guide profile's admission medication reconciliation feature docid\ x5ygt7otdwhuqpq2rdhabconfigure and setup the admission medication reconciliation feature in profile docid\ jqnurrfmfzw4taw mcoaafaqs admission medication reconciliation docid\ c3uttcinfw0eqgyiuglvgprofile's admission medication reconciliation feature docid\ slyqibth24jmy5c eg2mreview the medchart for a patient in profile docid\ abzjd iwqxzfneby0k5vpcreate and manage medication orders from a new encounter in profile docid\ d0sjnlmfrfa8bq7eeefn0create and view new medication orders or new ad hoc medication orders from the medchart view in profile docid\ l7lxss8mxmf9dpioxx 5jdocument medication administration using careflow in profile docid\ w6jiu64bfxdfo5rvunhmz