CHPPC Module 15, Section 1: Admission Med Rec
MODULE 15: TRANSITIONS OF CARE & DISCHARGE MED REC

Section 1: Admission Med Rec

This section is a masterclass in the foundational act of inpatient medication safety. The medication reconciliation performed upon admission is the single most important document you will create, as it forms the bedrock upon which all subsequent therapeutic decisions are built. An error here is a crack in the foundation that will compromise the integrity of the patient’s entire hospital stay. We will transform your expert community pharmacy skill of taking a medication history into a rigorous, investigative process designed for the high-stakes hospital environment. You will learn the multi-source techniques required to create the “Best Possible Medication History” (BPMH), a document that serves as the single source of truth and your most powerful tool for preventing errors at their very source.

1.1 The BPMH: More Than a List, It’s an Investigation

Defining the gold standard of medication history taking.

A Best Possible Medication History (BPMH) is not simply a transcription of what a patient says they are taking. It is a comprehensive, verified, and reconciled list compiled through a systematic process of interviewing the patient and/or their caregiver and cross-referencing that information with at least one other reliable source (e.g., pharmacy fill records, prior medical notes, pill bottles). This investigative process is designed to overcome the well-documented limitations of any single source of information. The initial medication list documented in the Emergency Department, often taken quickly by a non-pharmacist provider in a high-pressure environment, is frequently incomplete or inaccurate. Your role as the pharmacist is to take this preliminary list and elevate it to the level of a BPMH, correcting errors and filling in gaps before they can be propagated into the inpatient medication orders.

Retail Pharmacist Analogy: The “New Patient Transfer” Deep Dive

A patient comes to your counter and asks to transfer all their prescriptions from a competitor pharmacy. They hand you a single empty bottle for atorvastatin. Do you just transfer that one prescription? Of course not. You become a detective. You have the patient sign a release form. You call the other pharmacy and get a complete list of their active prescriptions. You ask the patient, “Besides what that pharmacy has, do you get any prescriptions by mail order, or from the VA?” You check the state’s Prescription Drug Monitoring Program (PDMP) database to see if they are getting controlled substances from other prescribers. You ask about OTCs and supplements. Through this multi-source investigation, you transform a single data point—one empty bottle—into a complete, accurate, and safe patient profile.

This is the exact workflow and mindset required to create a BPMH. The patient interview is just one piece of the puzzle. You must integrate data from multiple sources to build a complete picture, because you know from experience that relying on a single source is a recipe for error.

1.1.1 Why the Pharmacist is the Gold Standard

Numerous studies have demonstrated that when pharmacists are responsible for conducting medication reconciliation, the number of clinically significant errors is drastically reduced compared to when the task is performed by other healthcare professionals. Your unique training and experience make you the ideal candidate for this investigative role.

  • Expertise in Outpatient Systems: You instinctively know how to interpret pharmacy fill records, recognize NDC numbers, and navigate the complexities of PBM data. You understand the difference between a “refill too soon” rejection and a “prior authorization” rejection. This is a foreign language to most other providers.
  • Deep Drug Knowledge: You can instantly recognize common brand/generic pairs, identify therapeutic duplications, and ask targeted questions about high-risk drug classes.
  • Patient Counseling Experience: You have spent your entire career honing the skill of talking to patients about their medications in a clear, non-judgmental way. You know how to ask the right questions to uncover non-adherence and misunderstandings.
  • Investigative Mindset: Your daily work of resolving ambiguous prescriptions and DUR alerts has trained you to be a clinical detective, to question everything, and to seek out corroborating evidence before making a final determination.

1.2 The Art of the Investigation: A Masterclass on Information Gathering

A deep dive into the strengths and weaknesses of every available source.

A successful BPMH is built by synthesizing information from multiple, imperfect sources. Your skill as an investigator is to understand the biases and limitations of each source and use them to corroborate or challenge one another. The bedside rounding workflow gives you the unique advantage of being able to gather information from the patient and their environment that is unavailable to a remote pharmacist.

1.2.1 The Sources of Truth: A Comparative Analysis

Let’s conduct a deep dive into the sources you will use to build your BPMH, focusing on the practical “how-to” of extracting the most value from each.

Source 1: The Patient Interview (The Primary Narrative)

The patient is your most valuable source, but also potentially the most unreliable. Your interview technique is everything. This is where your bedside presence shines.

Strengths:

  • Provides insight into actual adherence (“as taken”) vs. prescribed directions (“as written”).
  • The only source for OTC, herbal, and supplement use.
  • Allows clarification of allergies and adverse reactions (e.g., “nausea” vs. “anaphylaxis”).
  • Can uncover social barriers to care (cost, transportation, health literacy).

A Masterclass on Interview Technique:

  1. Set the Stage: Introduce yourself clearly. “Good morning, I’m the pharmacist. I’m here to talk with you to make sure we have a perfect list of your home medications. This helps us keep you safe while you’re here.” This frames the interview around a shared goal and establishes your role as a safety expert.
  2. Start with Open-Ended Questions: Begin with broad prompts to get the patient talking. “Can you tell me about the process you go through when you take your medicines each day? Let’s start with the morning.” This “storytelling” approach often jogs the memory better than a direct list and can reveal important behavioral details.
  3. Use Probing Questions for Each Medication: For each drug mentioned, drill down with specific questions.
    • The “What For” Question: “What do you take that little white pill for?” The patient’s answer reveals their understanding of their own therapy and can uncover misunderstandings.
    • The “Last Dose” Question: “When was the last time you took a dose of your warfarin?” This is absolutely critical for anticoagulants, anti-epileptics, and insulin before procedures or surgery to assess risk.
    • The “How Much” Question: “Is that the 10 milligram tablet or the 20?” Patients may not know, but asking can reveal important clues and prompt them to think more carefully.
    • The “How do you ACTUALLY take it?” Question: Phrasing is key. “The bottle says to take it twice a day. How many times a day have you been taking it recently?” This non-judgmental phrasing can elicit a more honest answer about non-adherence.
  4. The “What Else” Funnel: Systematically screen for commonly forgotten medications.
    • “What about things that aren’t pills? Any inhalers, eye drops, ear drops, creams, or patches?”
    • “What about things you get over-the-counter? Anything for pain, sleep, allergies, or your stomach?” (Use brand names: “Like Tylenol, Advil, Benadryl, or Prilosec?”).
    • “Any vitamins, herbs, or natural supplements?”
    • “What about medications you only take once in a while, or as needed?” (e.g., PRN nitrates, pain meds).
  5. Dealing with Challenging Interviews:
    • Cognitively Impaired Patients: Immediately ask, “Who is the person who usually helps you with your medications at home?” and seek to interview that caregiver, with the patient’s permission.
    • Poor Historians: If the patient is unsure about doses, use visual aids. “Was it a small blue pill or a larger white one?” Pull up images of the tablets on a mobile workstation if possible.
    • Health Literacy Barriers: Avoid medical jargon. Instead of “antihypertensive,” say “blood pressure pill.” Frame questions simply.

Source 2: Pharmacy Fill Records (The Objective Timeline)

Your background in community pharmacy makes you an unparalleled expert in interpreting this data. This is your chance to corroborate the patient’s story with an objective, dated record of what was actually dispensed.

How to Access and Interpret:

  • Access: Many EHRs have integrated links to PBM/Surescripts data. If not, you may need to call the patient’s outpatient pharmacy directly. Your bedside interview is where you ask, “Which pharmacy or pharmacies do you usually use? Is it okay if I call them to get a list?”
  • Interpreting the Data: You are looking for patterns and red flags.
    • Adherence Clues & PDC: The patient says they take their statin every day, but the fill history shows a 90-day supply was last filled 6 months ago. This is a major discrepancy. You can do a quick Proportion of Days Covered (PDC) calculation: (Days’ supply filled in a period / Number of days in the period). A PDC <80% suggests significant non-adherence.
    • Early Refills: A patient is getting 30-day supplies of oxycodone every 20 days. This is a red flag for overuse, diversion, or escalating pain that needs to be communicated to the team.
    • Discontinued Drugs: The record shows the patient was switched from lisinopril to losartan 3 months ago, but the patient only mentions lisinopril. The record helps you identify the more current regimen.
    • Multiple Pharmacies/Prescribers: The record can reveal “doctor shopping” or the use of multiple pharmacies, which is critical for controlled substance surveillance via the PDMP.
    • “Refill Too Soon” Rejections: While this often indicates an attempt to get a med early, in the context of a hospital admission, it can be a clue that the patient has lost their medication or had it stolen, which is important social information.

Source 3: Patient’s Own Pill Bottles (The Ground Truth)

If the patient or family has brought the home medications to the hospital, you have found a goldmine. This is your best opportunity to see the “ground truth” of what the patient actually has in their possession. Your bedside rounding gives you the opportunity to perform this review in person.

Your Bedside Bottle Review Workflow:

  • Ask the Nurse First: Always coordinate with the nurse. “Hi, I’m here to do a med rec on Mr. Smith. Did the family bring in his bag of home meds? Can we look at them together?”
  • Line Them Up: Empty the bag and line up all the bottles. Systematically go through each one.
  • Check the Label vs. the Contents: Does the tablet in the bottle match the description on the label? Use your pill identifier app (or experience) to confirm. This is your chance to catch errors where a patient may have mixed multiple medications in one bottle (a “pill salad”).
  • Look at Fill Dates and Quantity Remaining: A bottle of 30 tablets filled two months ago that is still half full is a powerful, objective indicator of non-adherence that you can discuss with the patient. “I see this was filled a while ago. It looks like you have quite a few left. Can you tell me how you’ve been taking this one?”
  • Identify the Prescriber and Pharmacy: The labels give you the exact source of the prescription, which is invaluable if you need to call for clarifications. Look for multiple prescribers for the same class of drug.
  • Policy and Disposition: After your review, you must follow your hospital’s policy for “patient’s own medications.” In most cases, they must be sent home with family or stored securely by the pharmacy. They cannot be kept at the bedside for the patient to self-administer, as this is a major source of error (e.g., patient takes their own home diuretic in addition to the IV diuretic the nurse just gave).

1.3 Synthesizing the Data and Resolving Discrepancies

Moving from investigator to adjudicator: Creating the final, verified list.

After you have gathered information from all available sources, the final cognitive step is to synthesize this data into a single, verified BPMH. This is where you will inevitably find discrepancies—conflicts between what the patient said, what the pharmacy record shows, and what the previous doctor’s note claims. Your job is to be the final adjudicator, using your clinical judgment and, when necessary, further investigation to resolve these conflicts and create the definitive list.

1.3.1 Common Discrepancy Types and Your Action Plan

Let’s explore the most common types of discrepancies and the pharmacist’s systematic approach to resolving them.

Discrepancy Type Example Your Investigative Process & Action
Omission A patient with a history of seizures does not mention their home levetiracetam. The pharmacy record shows it was filled 2 weeks ago. Action: Go back to the patient. Use a direct, non-judgmental question. “Mr. Davis, I see from your pharmacy that you also take a medication called levetiracetam, for seizures. Can you tell me about that one?” The patient may have simply forgotten. This intervention prevents a potentially catastrophic in-hospital seizure.
Commission / Duplication The patient’s pharmacy record shows active prescriptions for both lisinopril (from their PCP) and losartan (from their cardiologist). The patient reports taking “a blood pressure pill.” Action: This requires a call to one or both prescribers’ offices and/or the outpatient pharmacies. Your retail experience is key here. The goal is to determine the most recent, intentional therapy. “Hi, this is the pharmacist at University Hospital. We have your patient, Mrs. Miller, admitted. I’m trying to clarify her home regimen. Your records show you started losartan last month. Can you confirm if the plan was to stop the lisinopril that her PCP was prescribing?”
Dose/Frequency Mismatch The patient states they take metoprolol 25mg twice a day. The pill bottle they brought in says “Metoprolol Succinate 50mg, take one daily.” Action: This is a classic source of confusion. Show the bottle to the patient. “The label on this bottle says to take one of these 50mg tablets a day. Is this what you’ve been doing?” The pill bottle is often the source of truth here. Clarify if the patient has been cutting the tablets. This prevents a potential inpatient order for the wrong dose (tartrate vs. succinate) or frequency.
Non-Adherence The BPMH shows the patient is prescribed apixaban 5mg BID for atrial fibrillation. During the interview, the patient confides, “I only take that pill once a day because it’s too expensive.” Action: This is a critical clinical finding. 1) Document this adherence issue clearly in your medication history note. 2) Verbally communicate this finding to the admitting physician. This information is crucial for interpreting the patient’s clinical presentation (e.g., a new stroke) and for planning the discharge regimen (e.g., involving social work to address cost barriers).

Documenting Your Investigation: The Med Rec Note

Once your investigation is complete, you must document your findings and actions in a formal pharmacy progress note. This note serves as the legal record of the BPMH and communicates your valuable findings to the entire team.

Gold Standard Med Rec Note Template (SOAP Format):

Admission Medication Reconciliation

S: Patient interviewed at bedside. Patient is alert and oriented, and a reliable historian. Daughter (Jane Doe) also present and contributed to history.

O: Sources used to compile history:
1. Patient and daughter interview.
2. Review of patient's own medication bottles brought from home.
3. Review of outpatient pharmacy fill data from ABC Pharmacy (last 12 months).
4. Review of discharge summary from prior admission on 05/15/2025.

--- Best Possible Medication History ---
[List the final, adjudicated list of medications here, including drug, dose, route, frequency, and last dose information.]
- Atorvastatin 40mg PO daily. (Last dose yesterday evening)
- Losartan 50mg PO daily. (Last dose this AM)
- Metformin 1000mg PO BID. (Held this AM due to N/V)
...etc.

A: The following clinically significant discrepancies were identified and resolved:
1. Therapeutic Duplication: Patient's outpatient records showed active Rxs for both lisinopril and losartan. Per patient and daughter, the lisinopril was discontinued 3 months ago by cardiology and replaced with losartan. Verified this with a call to the cardiologist's office. Lisinopril was removed from the BPMH.
2. Non-Adherence Identified: Patient reports only taking her atorvastatin "a few times a week" due to concerns about side effects she read about online. This was communicated to the admitting team.
3.  OTC Discovery: Patient reports taking ibuprofen 800mg three times daily for arthritis pain, which was not previously documented. This is a critical finding given the patient was admitted for an upper GI bleed. This was highlighted for the primary team.

P:

The Best Possible Medication History has been documented and reconciled in the EHR. All home medications have been addressed (continued, held, or discontinued) on the admission order set.

Key findings, including the therapeutic duplication, atorvastatin non-adherence, and high-dose NSAID use, were verbally communicated to the admitting physician, Dr. Evans.

Will continue to monitor pharmacotherapy throughout the admission.

1.4 The BPMH as a Living Document: Your Ongoing Responsibility

Using your foundational work to guide the entire hospital stay.

Creating the BPMH is a monumental achievement, but its value is only realized when it is actively used to guide therapy and prevent harm. Your role does not end when you sign your med rec note. This foundational document now becomes your primary tool for clinical surveillance and intervention throughout the patient’s admission.

  • Guiding Admission Orders: The immediate purpose of the BPMH is to allow the admitting provider to make intentional decisions about each of the patient’s home medications. They will decide to “Continue,” “Hold,” or “Discontinue” each one. Your role is to ensure these decisions are safe and appropriate (e.g., ensuring a chronic anti-epileptic is continued, while a potentially harmful NSAID is held in a patient with kidney injury).
  • Informing Clinical Decisions: The accurate BPMH provides the necessary context for all subsequent prescribing. Is the patient’s current delirium due to their underlying illness, or is it because their home clonazepam was abruptly held? Is their high blood pressure a new problem, or is it because their three home antihypertensives are not being given? Your BPMH holds the answer.
  • The Foundation for Discharge: The entire process comes full circle at the end of the hospital stay. The discharge medication reconciliation, which we will cover in the next section, begins by comparing the patient’s inpatient medications back against the original, gold-standard BPMH you created on admission. This is the only way to ensure a safe and seamless transition back to the outpatient setting.

The Pharmacist’s Superpower: Creating Clarity from Chaos

Never underestimate the value of the service you provide when you complete a BPMH. A patient’s medication history is often a chaotic, fragmented, and confusing narrative scattered across multiple providers, pharmacies, and memories. Your investigation brings order to this chaos. You create a single, reliable source of truth that becomes the bedrock of the patient’s medication safety for their entire hospitalization. This act of creating clarity from chaos is one of the most powerful, high-impact interventions a hospital pharmacist performs, preventing countless errors and solidifying your role as an indispensable member of the patient care team from the moment of admission.