Clinical Pharmacy Technician Medication Reconciliation within

the VAKara Jackson

Clinical Pharmacy TechnicianMinneapolis, MN

Medication Reconciliation FlowUpon admission: patient/caregiver/etc. interviewed

by pharmacy (technician or pharmacist)Med Recon Note entered into CPRS listing how

patient actually takes medications (versus Rx direction)

Physician uses Med Recon Note to order inpatient medications

Clinical pharmacist uses Med Recon Note to reconcile inpatient orders (versus home medications)Identifies discrepancies or problems and clarifies

with physician

1. Patient Roster

Assignment of PATIENTS to their corresponding Clinical pharmacists & by Medical team affiliation

• Vista: inpatient roster report to file• Import into Excel® via text import wizard• Excel®: able to sort by ward, patient name,

RPh, medical team, etc…

Roster – Technician responsibilities (cont)Supply clinical pharmacists w/daily staffing

scheduleIdentify patient “name alerts”Identify drugs that require special monitoring

gentamicin, tobramycin, vancomycin, enoxaparin, warfarin, heparin, argatroban, phytonadione tab, phytonadione inj

Provide copies to Pharmacy staffMaintain current medical resident/team

assignmentsResidents rotate x2 monthly (teaching hospital)

Daily Roster: ExampleName Ward Bed TEAM Clinical RPh AD RPh Drug

Patient 2LT 2L108-1 SURGERY Inna Michelle vanco

Patient 2LV 2L120-2 SURGERY Inna Michelle  

Patient 2LG 2L132-1 SURGERY Inna Michelle  

Patient 2LT 2L118-3 SURGERY Inna Michelle vanco

Patient 2LS 2L128-4

SURGERY Inna Michelle  

Patient 2LS 2L104-1 SURGERY Inna Michelle vanco

Patient 3F 3F118-1 GOLD Mara Mary vanco

Patient 3LS

3L135-1 V1 Mara Mary heparin/warfarin

Patient 3L 3L102-1 GOLD Mara Mary warfarin

Patient 3LS

3L109-1 HOLDOVER Mara Mary  

Patient 3L 3L134-1 HOLDOVER Mara Mary  

2. Interviewing/Obtaining Medication History (Medicine Admits)After daily Rosters completed, 1st order of

day is to interview patients admitted overnight

“Holdovers” = overnight admissions typically not interviewed by pharmacy yet

Work with clinical pharmacists to get all “Holdover” interviews completed

2. Interviewing/Obtaining Medication History - Medicine Admits (cont)

New Admissions throughout the day

VISTA report (L24): real time notification of admits Clinical technician monitors through the day Will assist clinical pharmacists with interviews if needed/available

Emergency Room: check in to ER @ 1000, 1200, 1400 Communicate with ER Physicians – who are they admitting to

hospital? Communicate with ER Pharmacist

Communicate admits to clinical pharmacists Enter Med Recon Note in CPRS Update “MEDICINE Med Recon List” which department uses as a

communication tool (Excel® spreadsheet)

Medicine Med Recon List

DATE OF ADMIT

Patient name; SSN; WardDROA

Done (in CPRS)?

ADD'L SIGNER

Assigned?

Final Recon Done

(DROA Reconcile

d w/ IP Orders)

Comments

01/01/10 Jordan,Michael 1234 3F Yes Yes arh kara

01/01/10 Smith,John 1234 ER--->MICU (Yes) NO Vet's Home patient (kara in progress)

01/01/10 Doe,Jane 1234 2L husband organizes meds - on his way to hospital

01/01/10

01/01/10

01/01/10

3. Surgery Med ReconAnticipate all Surgical patients who will be

admitted to hospital (post-op)Vista: search by appointment title and other

sourcesAdd patients to : “SURGERY Med Recon List”

utilized as a communication tool (Excel® spreadsheet)

Begin calling patients 3-4 day prior to surgeryEnter Med Recon Note in CPRS

include pre-op medication instructionsMD added as additional signer on day of surgery

Schedule of Operations

@ 1430 daily: Surgical Service sends copy of “Schedule of Operations” for the following day

Check schedule for last minute surgical add-on’sAnticipated admits listed with post-op

disposition: WARD &/or 2LOBSAdd names to “SURGERY Med Recon List”Set up document(s) & call patientCommunicate to Access Clinic technician

Access Clinic Technicians

Technicians available as “back-up”Available to make phone calls/interview 2KOBS

patients after 1530 Communicate evening duties via “SURGERY Med

Recon List” &/or verbal instruction

Provide coverage in [my] absence (SURGERY Med Recon ONLY)

(trial): assist evening AD with Medicine admits

In Conclusion:Summary of Responsibilities:

Organize and maintain Roster(s): assign pharmacists to their patients (by team & MD)

Organize communication tools Roster(s), Med Recon Lists(s), L24

Interview Medicine admitsInterview Surgery admits

Anticipate admits, set up documents, & call 3-4 days in advance

Provide guidance to Access Clinic technicians