CMS requires that medication reconciliation and management be provided to patients on or before the face-to-face visit date. As AAFP states, "Transitional care management medication reconciliation requires the medications on discharge to be reconciled with the medications the patient was taking previously."

The medication reconciliation SOP requires implementation of a standardised process of medication reconciliation whenever care is transferred. That is, on admission, transfer within the hospital and on discharge from hospital to home or a long term care facility (nursing home).

The “gold standard medication history” is created by a licensed pharmacist interviewing the patient to identify what medications the patient was taking prior to admission to the hospital.

A good medication history should encompass all currently and recently prescribed drugs, previous adverse drug reactions including hypersensitivity reactions, any over-the counter medications, including herbal or alternative medicines, and adherence to therapy.

Four-step process Verify (collect a current medication list) Clarify (make sure the medications and doses are appropriate) Reconcile (compare new medications with the list and document changes in the orders) Transmit (communicate the updated and verified list to the appropriate caregivers).

Medication reconciliation involves a three-step process: verification (collecting an accurate medication history); clarification (ensuring that the medications and doses are appropriate); and reconciliation (documenting every single change and making sure it “squares” with all the other medication information).

This process comprises five steps: (1) develop a list of current medications; (2) develop a list of medications to be prescribed; (3) compare the medications on the two lists; (4) make clinical decisions based on the comparison; and (5) communicate the new list to appropriate caregivers and to the patient.