The process for reconciliation of medication is the responsibility of the prescriber. It is important to remember that the registered nurse is not authorized or approved to sign orders that must be reconciled with patient medication. Medication reconciliation is a formal process for creating the most complete and accurate list possible of a patient’s current medications and comparing the list to those in the patient record or medication orders. The purpose of reconciliation is to avoid errors that include but are not limited to transcription, omissions, duplication, dosing errors, or drug interactions. Taking a medication history has always been part of the nursing assessment and this information should be conveyed to the prescriber. The NCQAC suggests the following:
- Follow the policies and procedures relative to the documentation (paper or electronic) system used by the organization;
- Collect and verify the patient’s complete medication history;
- Clarify that the medications and dosages taken by the patient are correct and enter the information into the patient’s record;
- Notify provider of updated list; and
- Licensed prescriber reviews the medications list and reconciles.