Medication Reconciliation

Overview

Perform medication reconciliation per Joint Commission NPSG.03.06.01 requirements. Pull all medication sources (MedicationRequest, MedicationStatement, MedicationAdministration), normalize into a unified list, and identify discrepancies including duplicates, therapeutic duplications, discontinued medications still listed as active, and dose discrepancies across care settings.

FHIR Resources Used

Resource	Purpose	Key Fields
MedicationRequest	Prescribed medications (orders)	status, intent, medicationCodeableConcept, dosageInstruction, authoredOn
MedicationStatement	Patient-reported and reconciled meds	status, medicationCodeableConcept, dosage, effectivePeriod, informationSource
MedicationAdministration	Administered medications (inpatient)	status, medicationCodeableConcept, dosage, effectiveDateTime, context
Patient	Patient demographics for identity verification	name, birthDate, identifier
AllergyIntolerance	Cross-check for contraindicated meds	code, clinicalStatus, reaction
Condition	Validate indication for each medication	code, clinicalStatus

Instructions

Step 1: Verify Patient Identity

code

Tool: fhir_search
resourceType: "Patient"
queryParams: "family=[lastname]&given=[firstname]&birthdate=[YYYY-MM-DD]"

Confirm at least 2 identifiers match. If multiple patients returned, present options and halt until user confirms.

Step 2: Pull All Medication Sources in Parallel

2a: Prescribed medications (orders)

code

Tool: fhir_search
resourceType: "MedicationRequest"
queryParams: "patient=[patient-id]&status=active,on-hold&_include=MedicationRequest:medication&_count=100"

2b: Patient-reported medications

code

Tool: fhir_search
resourceType: "MedicationStatement"
queryParams: "patient=[patient-id]&status=active,intended,on-hold&_count=100"

2c: Administered medications (inpatient context)

code

Tool: fhir_search
resourceType: "MedicationAdministration"
queryParams: "patient=[patient-id]&effective-time=ge[admission-date]&_count=100"

Step 3: Pull Allergies and Active Conditions

3a: Allergies

code

Tool: fhir_search
resourceType: "AllergyIntolerance"
queryParams: "patient=[patient-id]&clinical-status=active"

3b: Active conditions

code

Tool: fhir_search
resourceType: "Condition"
queryParams: "patient=[patient-id]&clinical-status=active"

Step 4: Normalize and Compare

For each medication entry, extract:

•Generic name (prefer RxNorm coding, system http://www.nlm.nih.gov/research/umls/rxnorm)
•Dose quantity and unit
•Frequency (from dosageInstruction.timing)
•Route (from dosageInstruction.route)
•Source (MedicationRequest vs MedicationStatement vs MedicationAdministration)
•Status and last updated date

Step 5: Identify Discrepancies

Flag the following categories:

Duplicates: Same RxNorm code appearing in multiple sources with identical dose/frequency. Mark for deduplication.

Therapeutic Duplications: Different medications in the same therapeutic class (e.g., two SSRIs, two ACE inhibitors, two statins). Use drug class grouping by RxNorm ingredient.

Discontinued Medications Still Active: MedicationRequest with status stopped or cancelled but a corresponding MedicationStatement with status active. Flag with the discontinuation date.

Dose Discrepancies: Same medication across sources with different dose or frequency. Present both values side by side.

Missing Indications: Active medications with no matching active Condition. Flag for clinician review.

Allergy Conflicts: Active medication matching a documented AllergyIntolerance substance code.

Step 6: Flag High-Alert Medications

Cross-reference active medications against the ISMP high-alert medication list (see references/high-alert-medications.md). Apply extra scrutiny to:

•Anticoagulants (warfarin, heparin, DOACs)
•Insulin (all formulations)
•Opioids (all formulations)
•Antiarrhythmics (amiodarone, sotalol)
•Chemotherapy agents
•Concentrated electrolytes (KCl, NaCl >0.9%)

Step 7: Present Reconciliation Report

Structure output as:

•Verified Medication List - Unified, deduplicated list with source attribution
•Discrepancies Found - Categorized by type with recommended resolution
•High-Alert Medications - Highlighted with safety notes
•Allergy Conflicts - Any medication-allergy matches
•Recommendations - Specific actions (discontinue, adjust dose, clarify with prescriber)

Step 8: Update Reconciled Medications (if authorized)

For each reconciled medication, update the MedicationStatement:

code

Tool: fhir_update
resourceType: "MedicationStatement"
id: "[medication-statement-id]"
resource: {
  "resourceType": "MedicationStatement",
  "status": "active",
  "statusReason": [{"text": "Reconciled on [date]"}],
  "dateAsserted": "[current-date]"
}

For medications to discontinue:

code

Tool: fhir_update
resourceType: "MedicationRequest"
id: "[medication-request-id]"
resource: {
  "resourceType": "MedicationRequest",
  "status": "stopped",
  "statusReason": {"text": "Discontinued during medication reconciliation [date]"}
}

Examples

Example 1: Admission Medication Reconciliation

User says: "Reconcile medications for patient John Smith, DOB 1955-03-15, being admitted to the hospital."

Actions:

•Search Patient with family=Smith&given=John&birthdate=1955-03-15. Confirm identity.
•Pull MedicationRequest (active orders), MedicationStatement (home meds), and MedicationAdministration (if transfer from another facility).
•Pull AllergyIntolerance and active Conditions.
•
Normalize all entries. Discover:
- •MedicationStatement: lisinopril 10mg daily (home med)
- •MedicationRequest: lisinopril 20mg daily (new order)
- •MedicationStatement: metformin 500mg BID (home med)
- •No corresponding MedicationRequest for metformin
•Flag: Dose discrepancy on lisinopril (10mg home vs 20mg ordered). Missing order for metformin.
•Check high-alert list: no high-alert meds active.

Result:

code

MEDICATION RECONCILIATION - John Smith (DOB: 1955-03-15)
Reconciled: [date]

VERIFIED MEDICATIONS:
1. Lisinopril - HOME: 10mg daily | ORDERED: 20mg daily [DOSE DISCREPANCY]
2. Metformin 500mg BID - HOME only [NO INPATIENT ORDER]
3. Atorvastatin 40mg daily - HOME and ORDERED [MATCHED]

DISCREPANCIES:
- Lisinopril: Dose differs between home (10mg) and inpatient (20mg). Clarify with prescriber.
- Metformin: On home list but no inpatient order. Intentional hold or omission?

RECOMMENDATIONS:
- Confirm lisinopril dose change is intentional
- Confirm metformin hold (common for inpatient with contrast risk) or add order

Example 2: Discharge Medication Reconciliation

User says: "Prepare discharge med rec for patient ID 12345."

Actions:

•Read Patient 12345 via fhir_read. Confirm identity.
•Pull all medication sources. Compare inpatient orders vs pre-admission home meds.
•Identify new medications started during admission, medications discontinued, dose changes.
•Flag any high-alert medications being sent home (insulin started during admission, new anticoagulant).

Result:

code

DISCHARGE MEDICATION RECONCILIATION - Patient 12345
Reconciled: [date]

CONTINUE FROM HOME:
1. Amlodipine 5mg daily [UNCHANGED]
2. Omeprazole 20mg daily [UNCHANGED]

NEW MEDICATIONS (started during admission):
3. Apixaban 5mg BID [HIGH-ALERT: anticoagulant] - Indication: new atrial fibrillation
4. Metoprolol succinate 25mg daily - Indication: rate control for atrial fibrillation

DISCONTINUED:
5. Ibuprofen 400mg TID - Reason: interaction with apixaban (bleeding risk)

DOSE CHANGES:
6. Lisinopril: Changed 10mg -> 20mg daily - Reason: BP not at goal

PATIENT EDUCATION REQUIRED:
- Apixaban: bleeding precautions, no NSAIDs, consistent dosing
- Metoprolol: check heart rate before taking, do not stop abruptly

Troubleshooting

MedicationRequest returns 0 results but patient has known medications

•Try searching MedicationStatement instead; some systems store home medications only as statements.
•Check if the EMR uses contained Medication resources: add _include=MedicationRequest:medication to resolve inline references.
•Verify the patient ID is correct. Some systems use different ID formats across modules.

Medication codes are missing or use local codes instead of RxNorm

•Fall back to medicationCodeableConcept.text for display name matching.
•Search by medication text: fhir_search with resourceType: "MedicationRequest" and queryParams: "patient=[id]&code:text=[medication-name]".
•Note in the reconciliation report that code-based matching was unavailable and manual review is required.

MedicationAdministration not supported by the FHIR server

•This resource is optional in many implementations. Proceed with MedicationRequest and MedicationStatement only.
•Document that administered medications could not be verified and recommend manual chart review for inpatient administrations.

Related Skills

•drug-interaction-checker - Run after reconciliation to check the unified list for interactions
•prescription-appropriateness-review - Validate reconciled list against Beers/STOPP-START criteria for elderly patients
•medication-adherence-assessment - Assess fill history for reconciled home medications
•clinical-summary-generator - Include reconciliation results in clinical summary