How To Use Medication Reconciliation (for medications)

The purpose of this knowledge base article is to guide users on how to utilize the Medication Reconciliation section of ICANotes to accurately document all medications a patient is currently taking at the time of admission or during their initial office visit.

ADMISSION RX

1. To access the medication reconciliation area, click the button on a Nursing Note, Prescriber Progress Note or Complete Evaluation (only for Prescribers).

Form the Nursing Note (When the Medication Reconciliation is not going to be entered by the Prescriber): The Medication Reconciliation button is located in section 3. Interventions as shown Below.

From Prescriber Progress Note: the Medication Reconciliation button is in PN Part 2 as shown below.

Progress Note (Classic):

Progress Note (New Layout):

From the Complete Assessment: the Medication Reconciliation button will only be available to Prescribers. The button is located in the Finish Initial tab as indicated below.

2. The reconciliation form opens to the admission RX window.

3. Click the on the left side to add a medication under Step 1 to open the fields to add a new medication.

4. Click if you wish to add more details to the prescription. This option is only available when adding medications in Step 1.

5. Step 2 is where a prescriber decides how to proceed with the medication.

continue: the medication, dose, route, and timing remains the same
continue but change: the medication dose, route, and timing can be changed
external provider Rx: used in outpatient setting to document medications that another doctor prescribes
hold/stop: used in inpatient setting to hold or stop a medication during the patient's admission.

a. Clicking continue will bring you to the RX Order Review window for the prescriber to review the medication:

Clicking will add the medication to the column on Step 3.
Clicking will delete the action and return the user back to the medication reconciliation screen.

b. Clicking continue but change will bring you to the RX Order Review with the dose, route, qty, and timing blank. Fill in the fields as desired and click to add to Step 3.

c. Clicking external provider Rx will bring you to the RX Order Review to confirm data entered. Click to add medication to Step 3.

d. Clicking hold/stop will bring up a popup window to confirm the action:

Clicking will hold the medication:

A confirmation message will pop up, click on to hold the medication or if you want to delete the action and return you to Step 2.

Clicking will stop the medication:

6. Step 3 is where the prescriber reviews the medications and creates the Medication Reconciliation note by clicking (the action taken in Step 2 is noted for each entry).

Note: Medications that were held will not be listed in Step 3.

A notice will populate indicating that a Medication Reconciliation Note has been Created:

7. Once confirmed, the medications will show on Medications in the work area.

8. This is a screenshot of the Med Reconciliation note:

9. Medications added through the Work Area will be automatically added to Step 3.

The Adverse Drug Reactions/Allergies will also populate in the Medication Reconciliation if entered in the Work Area.

RX DISCHARGE

1. Medications that were held at intake can be restarted from the window in the medication reconciliation area. This is done during the final Progress Note. Click the ‘Medication Reconciliation’ button and click the button at the top of the window.

2. The held medications will show in this window. Step 1 is read-only.

3. Step 2 shows three choices that can be chosen.

re-start: this will restart the medication at the previously prescribed dose, route, qty, and timing.
re-start but change: this will restart the medication but the dose, route, and timing can be changed
not recommended: this will not restart the medication

a. Clicking re-start will bring you to the RX Order Review window for the prescriber to review the medication.

Clicking will add the medication to the column on Step 3.
Clicking will delete the action and return the user back to the medication reconciliation screen.

b. Clicking re-start but change will bring you to the RX Order Review with the dose, route, qty, and timing blank. Fill in the fields as desired and click to add to Step 3.