Documentation of patient information Overview of what is required Suggested approach Examples of evidence 4.8 The clinical workforce reviewing the current medication orders against their medication history and medication patient’s prescriber’s plan, and reconciling any discrepancies 4.8.1 Current medicines are documented and reconciled at admission and transfer of care between healthcare settings Medication reconciliation improves consumer Define and document the types of consumers Policies, procedures and/or protocols that safety by mitigating the risk of a medication who may require medication reconciliation. define and prioritise the types of consumers incident. Consumers of your community health who may require medication reconciliation, and This may include determining which types of service who are prescribed or administered services/visits require medication reconciliation, include requirements for reconciling medicines medicines should have their medicines reconciled on service commencement, transition to another and how often it should be carried out. A healthcare setting or when services cease. when commencing services and when services screening or risk assessment approach may be cease. For long-term clients, additional appropriate for identifying consumers at risk. Implementation of a screening tool or risk reconciliation may be required. assessment tool. Identify existing and suitable procedures, guidelines or similar, for a formal, structured Audit of consumer clinical record with To achieve this action your community health process on reconciling medicines. documented medication reconciliation on service should: service commencement, transition and when Develop an implementation plan to integrate the ensure a process for a formal, structured services cease. process into existing workflow, using a process of medication reconciliation is multidisciplinary, quality improvement approach Audit of consumer clinical records with a implemented that involves consumers and carers in the completed medication management plan or integrate this process into existing work flows process. equivalent (hard copy or electronic). monitor workforce compliance with this process The plan might include: Orientation manuals, education resources and look for opportunities to improve this process. using the MMP or equivalent (hard copy or records of attendance at training by the workforce on processes for reconciling electronic) document to support the medicines. reconciliation process giving priority to reconciling medicines for consumers with a higher risk of experiencing medication-related adverse events, and where medicines have been commenced, changed or ceased during care provided by your community health service.
Documentation of patient information Overview of what is required Suggested approach Examples of evidence 4.8 The clinical workforce reviewing the patient’s current medication orders against their medication history and prescriber’s medication plan, and reconciling any discrepancies 4.8.1 Current medicines are documented and reconciled at admission and transfer of care between healthcare settings Medication reconciliation improves consumer safety by mitigating the risk of a medication incident. Consumers of your community health service who are prescribed or administered medicines should have their medicines reconciled when commencing services and when services cease. For long-term clients, additional reconciliation may be required. To achieve this action your community health service should: ensure a process for a formal, structured process of medication reconciliation is implemented integrate this process into existing work flows monitor workforce compliance with this process look for opportunities to improve this process. Define and document the types of consumers who may require medication reconciliation. This may include determining which types of services/visits require medication reconciliation, and how often it should be carried out. A screening or risk assessment approach may be appropriate for identifying consumers at risk. Identify existing and suitable procedures, guidelines or similar, for a formal, structured process on reconciling medicines. Develop an implementation plan to integrate the process into existing workflow, using a multidisciplinary, quality improvement approach that involves consumers and carers in the process. The plan might include: using the MMP or equivalent (hard copy or electronic) document to support the reconciliation process giving priority to reconciling medicines for consumers with a higher risk of experiencing medication-related adverse events, and where medicines have been commenced, changed or ceased during care provided by your community health service. Policies, procedures and/or protocols that define and prioritise the types of consumers who may require medication reconciliation, and include requirements for reconciling medicines on service commencement, transition to another healthcare setting or when services cease. Implementation of a screening tool or risk assessment tool. Audit of consumer clinical record with documented medication reconciliation on service commencement, transition and when services cease. Audit of consumer clinical records with a completed medication management plan or equivalent (hard copy or electronic). Orientation manuals, education resources and records of attendance at training by the workforce on processes for reconciling medicines.
Guide-to-the-NSQHS-Standards-for-community-health-services-February-2016.docx