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

Instructions

Step 1: Verify Patient Identity

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)

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

2b: Patient-reported medications

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

2c: Administered medications (inpatient context)

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

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

3b: Active conditions

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

Build a unified table with columns: Medication | Dose | Frequency | Route | Source | Status | Last Updated.

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:

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

Step 8: Update Reconciled Medications (if authorized)

For each reconciled medication, update the MedicationStatement:

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:

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:

1. Search Patient with family=Smith&given=John&birthdate=1955-03-15. Confirm identity.
2. Pull MedicationRequest (active orders), MedicationStatement (home meds), and MedicationAdministration (if transfer from another facility).
3. Pull AllergyIntolerance and active Conditions.
4. 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

1. Flag: Dose discrepancy on lisinopril (10mg home vs 20mg ordered). Missing order for metformin.
2. Check high-alert list: no high-alert meds active.

Result:

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:

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

Result:

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