Medication Reconciliation

All patients will have a medication reconciliation performed:

  • Upon admission (within 24 hours whenever possible)
  • At transfer to different settings and/or level of care
  • At discharge

Reconciliation is a three-step process to prevent: 

  • Omissions
  • Duplication of therapy
  • Adverse interactions with other medications


  • The nurse, pharmacist or pharmacy technician will obtain a list of medications from the patient to be reviewed by the physician for completeness and accuracy.
  • Physician(s) will indicate in the EMR which home medications to continue or discontinue upon admission.
  • A pharmacist is responsible for identifying duplication or potential drug interactions when verifying medication orders.
  • Physicians are responsible for collaborating with nurses and pharmacists in all steps of the process.
  • The physician will reevaluate all medications at discharge.  

Medication Responsibility