Ambulatory Medication Reconciliation Overview

Performing Medication Reconciliation in the Ambulatory Care setting is required when medication management is identified as a major component of care. Site leadership should be able to clearly define whether Ambulatory MedRec is in scope for your clinic.

Prior to any Medication in CST Cerner, a Best Possible Medication History (BPMH). must be performed. This can occur before or during the initial visit, or as the patient condition allows.

If your clinic uses a Recurring encounter type, the BPMH will show as performed after the first time it is signed. Your site may have policies about when and how often a BPMH needs to be re-assessed, and Outpatient MedRec re-performed.

Other ambulatory encounter types generally close at the end of each visit so it will be clear that BPMH and/or MedRec have not yet been performed in that encounter.

 

Ensure BPMH performed in CST CernerEnsure BPMH performed in CST Cerner

 

Performing Ambulatory Medication Reconciliation in CST Cerner

Click  from the Home Medications component within the Provider View to access the Outpatient Reconciliation screen.




Alternatively, click the Reconciliation  drop-down arrow from the Medication List screen and select Outpatient to display the Outpatient Reconciliation screen.

WARNING: Do not use the Admission or Transfer Reconciliation buttons for Ambulatory patients.  If Admission Reconciliation is used and a patient has another active encounter, medication changes may flow to the other encounter.

 

The respective medication types are readily identified by the following icons:

Documented Home Medications  :
Medications that were documented previously as being taken at home.

Prescribed Medications  :
Medications that were documented as prescriptions from a previous visit.

Ambulatory Medications  :
Medications that are currently being given in the ambulatory encounter.

Medications placed on another encounter will appear with a purple box adjacent to the medication type icon. Any medication reconciliation actions placed on these orders will be also be reciprocated on the other encounters.  Please carefully review orders from other encounters so as not to affect patient care at other clinics.

Select the corresponding radio button to initiate one of the available reconciliation actions for each medication type:

Continue  :
Selecting Continue signifies that the patient is currently taking this and will document the medication on the BPMH with this icon . If you choose Continue for an ambulatory medication , it will remain active on that encounter.

Prescribe  :
Selecting Prescribe will print a paper prescription for the patient to take to a community pharmacy and will document the medication on the BPMH with this icon .

Do Not Continue :
Selecting Do Not Continue will remove the medication from the BPMH if previously documented or prescribed.
If you choose Do Not Continue for an ambulatory medication , it will be discontinued on that encounter.

 

WARNING: If you Prescribe    a medication that originated on another encounter, the medication will be discontinued on the other encounter. The medication is copied and converted to a prescription on the current encounter. However, prescriptions will always be visible on a patient’s Documented Medication by Hx (BPMH) in PowerChart.

 

 

Acknowledging Home Medications

Outpatient providers are not obligated to continue, prescribe or stop unfamiliar documented home medications. Such orders may simply be acknowledged using the button.

You cannot use the Acknowledge Remaining Home Meds button for Outpatient Medications  . You will need to reconcile all Outpatient Medications.

 

Finish the Ambulatory Reconciliation

Click the Sign button beside Reconcile and, to finalize the Ambulatory reconciliation process.

 

After signing, any appropriate discharge prescriptions are generated and printed. Providers can select Do Not Send if no prescription printout is required.  

A report summarizing changes to a patient’s home medication can be generated for printing a Visit Summary for the patient, and/or documented in a Clinic Note.

 

 

Related Topics

Conduct Best Possible Medication History Using PharmaNet IntegrationConduct Best Possible Medication History Using PharmaNet Integration

Medication ReconciliationMedication Reconciliation

Related Positions

Provider

Pharmacist

Key Words

Ambulatory Med Rec

Outpatient Med Rec

BPMH

Last Updated: January 19, 2021