Medical Reconciliation Clinical Documentation Standard · 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

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


Frequency


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

Documents

Medical Reconciliation Clinical Documentation Standard · 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