Medical Staff Portal

Medication Reconciliation

Medication Reconciliation, commonly referred to as “MedRec”, is a formal process in which healthcare providers work collaboratively to identify the most comprehensive and accurate list of medications for the patient/resident at key transitions of care (admission, transfer and discharge). MedRec is a Patient Safety Initiative which falls under the umbrella of Medication Management.     

Goal: to minimize medication errors at key transitions of care (admission, transfer and discharge) via a systematic and comprehensive review of all of the medications a patient/resident is taking to ensure that medications being added, changed, or discontinued are carefully evaluated, documented and communicated.         

What is MedRec?

Frequently Asked Questions (FAQ)

MedRec e-Learning module - Coming Winter 2015!!

Why Do We Need MedRec?

MedRec is an internationally recognized Patient Safety Initiative focusing on medication safety. MedRec is addressed by Accreditation Canada’s Required Organizational Practices (ROPs) to improve effectiveness, coordination and communication of medication information between Healthcare Providers at key transitions of care.

What’s in It for Me?

Accreditation Canada

MedRec Implementation

Covenant Health is committed to initiating and supporting the MedRec work for the long term.  As such, MedRec will be implemented in a staged fashion from 2014 – 2018. Please be patient and stay tuned for MedRec implementation in your program area/unit.

Note for Program areas/units that have already implemented MedRec on admission: Please continue to follow your current MedRec Process; the MedRec Project Team will provide the support for implementation of transfer and discharge MedRec when your program area/unit is scheduled for implementation.

MedRec Implementation Schedule

MedRec Implementation Guideline

Change Request Form

MedRec Education

For MedRec Educational Materials please go to the Medication Management Workspace on CLiC.

MedRec on Admission

The cornerstone of the MedRec process upon admission is to develop the Best Possible Medication History (BPMH). It is a medication history/list which acts as the one "source of truth” of the patient/resident’s medication regimen prior to admission, to share and communicate across all disciplines.

The collection of a BPMH requires: A systematic process of interviewing the patient/resident and their family and/or  caregiver as one source of information whenever possible and reviewing at least one other reliable source (minimum 2 sources total) of information.

There are two models for completing MedRec at admission:Proactive/prospective model and retroactive /retrospective model  

Exception: Direct admits from another facility: In this case, the BPMH from the previous facility will be faxed over and serves as a history/reference only. A new BPMH is NOT to be completed. The admitting prescriber will refer to this document and any transfer orders received to order all desired admission medication orders on a Patient Care Orders sheet.

The admission BPMH then becomes the reference point for:

  1. Decisions to continue, discontinue, or modify the patient/resident’s medication regimen upon admission.
  2. Creating admission orders for the patient/resident once reviewed and signed by a prescriber.
  3. Determining the patient/resident’s medication regimen upon transfer/discharge.

Goal: compare the admission BPMH to admission medication orders to identify,communicate and resolve any discrepancies.

Studies have found that thoroughly completing an admission BPMH can minimize unintentional discrepancies (i.e. omissions, duplications, dosing errors, drug interactions, etc.) which may lead to medication errors.  

MedRec on Admission Resources

BPMH: Frequently Asked Questions (FAQ) 

BPMH Interview Guide Pamphlet Using Alberta Netcare for MedRec – Frequently Asked Questions (FAQ

MedRec on Transfer

For MedRec purposes, “transfer” refers to a change in the level of care or service within-facility.  (ex. Grey Nuns Surgery to Grey Nuns Internal Medicine).

Both the sending prescriber and the accepting prescriber are responsible to review, evaluate and reconcile all medications upon transfer.  This is a process already occurring in practice.

Goal: compare the current medications the patient/resident was receiving on the unit (Medication Administration Record (MAR) or medication profile) with those that were being taken at home (Best Possible Medication History (BPMH)) to determine if any medications need to be continued, restarted, discontinued or modified at the next level of care.

To formalize this process, there is no paper MedRec “tool” to be completed. In place, a sticker or stamp will be used and completed by the SENDING prescriber only. It simply serves as a way to consistently document that the BPMH and current medication orders have been reviewed prior to transfer. See How to Complete MedRec on Transfer for more information.

MedRec on Transfer Resources

How to complete MedRec on Transfer

Quick Guide for Transfer vs. Discharge

MedRec on Discharge

Discharge refers to the end of service provision by the care facility (i.e. the patient physically exits the current facility and subsequently goes home, or to a different care facility).  

Goal: compare the current inpatient medications (Medication Administration Record (MAR) or medication profile) with those that were being taken at home (BPMH) to determine the patient/resident’s discharge medications. This is documented on the MedRec Discharge Tool.

This tool serves as a discharge prescription or order which may be sent/faxed to the patient’s community Pharmacy and/or next service provider. A copy is also provided as a record for the patient, in conjunction with a copy of the discharge summary form. Additionally, education should be provided to the patient/resident or caregiver.

MedRec Evaluation & Measurement

The MedRec Auditing Process is determined by three (3) types of measures:

Success: percentage of patients with MedRec completed on admission/discharge

Quality for admission: percentage of sample population with all five (5) quality elements complete

  • Two or more sources for BPMH
  • Actual medication use verified by patient/family
  • Complete medication information (right name, dose, strength, route, frequency) 
  • Every medication accounted for in medication orders
  • Rationale included for continued, discontinued or changed medication orders

Quality for discharge: percentage of sample population with all three (3) quality elements complete

  • All medications on the admission BPMH were accounted for on discharge
  • Complete medication information (right name, dose, strength, route, frequency)
  • Rationale included for continued, discontinued or changed medication orders

Outcome: percentage of patients with one or more outstanding discrepancies

Note: measurement and evaluation strategies may change over time to ensure the measurement and evaluation strategies remain relevant and useful.       

MedRec Auditing Resources

MedRec Auditing Frequently Asked Questions (FAQ)

One Page - Auditor Responsiblities

Guide for Admission Audit Measures

Admission Audit Tool (Not For Use - obtain personalized tool from Crede Technologies)

Guide for Discharge Audit Measures

Discharge Audit Tool (Not For Use - obtain personalized tool from Crede Technologies)

Three Step Ladder System

Audit Action Plan Template

MedRec Tools

The MedRec process is facilitated by the use of tools at admission and discharge.

Admission BPMH Tool  CV# 0199 (Edmonton) & 0199NCR (Rural)

Transfer sticker template (No CV # - NOT ordered from DATA Group)

Printable sticker template is compatible with Avery labels (5162, 5262, 5522, 5662, 5962, 8162, 8252, 8462, and 8662)

Discharge MedRec Tool CV# 0375NCR

Child Health/NICU Tools:

Admission/Transfer Tool CV# 0426

Discharge Tool CV#0425

MedRec News & Updates

On Deck with MedRec - August 2016

On Deck with MedRec - Issue#4  (April 2016)

On Deck with MedRec - Issue #3 (September 2015)

On Deck with MedRec - Issue #2 (April 2015)

On Deck with MedRec - Issue #1 (September 2014)

Questions/Contact Information

Medication.Management@covenanthealth.ca