Medication Reconciliation in RXNT
Maintain an accurate medication list that reflects what the patient is actually taking.
Medication reconciliation is performed during every appropriate patient encounter to compare the patient's current medication list with what they are actually taking. Accurate medication documentation reduces prescribing errors, improves patient safety, and supports continuity of care.
← Return to RXNT CenterWorkflow Purpose
Medication reconciliation ensures the medication profile within RXNT accurately reflects the patient's current therapy before provider evaluation or prescribing decisions.
This workflow focuses only on documenting medication information inside RXNT. Clinical decisions regarding starting, stopping, or changing medications remain the responsibility of the licensed provider.
- Review every medication with the patient whenever possible.
- Confirm medications currently being taken.
- Identify medications that have been stopped.
- Review allergies and medication reactions.
- Document patient-reported compliance concerns.
- Prepare an accurate medication profile for provider review.
Critical Standards
Never assume the medication list is current simply because it appears in RXNT.
Whenever possible, confirm medications directly with the patient or caregiver.
Record what the patient reports without making clinical judgments regarding appropriateness.
Medical Assistants should not independently discontinue or prescribe medications unless specifically authorized by clinic protocol and scope of practice.
Medication Reconciliation Overview
Open Medication List
Review all active medications currently listed within RXNT.
Interview Patient
Confirm every prescription, OTC medication, vitamin, and supplement currently being taken.
Update RXNT
Document discontinued medications, missing medications, and patient-reported changes.
Review Allergies
Verify medication allergies and documented reactions.
Prepare for Provider
Ensure the medication profile is accurate before provider evaluation.
Medication Types to Review
Prescription Medications
Review dose, frequency, route, prescribing provider, and whether the patient is actively taking the medication.
OTC Medications
Document common non-prescription medications including pain relievers, allergy medications, acid reducers, and similar products.
Vitamins & Supplements
Review vitamins, herbal supplements, minerals, protein products, and other complementary therapies reported by the patient.
Medication Allergies
Verify allergies, reactions, and intolerances exactly as reported by the patient before provider review.
Patient Safety Reminder
Never assume that medications listed from a previous visit are still accurate. Medication reconciliation should be completed through direct patient verification whenever possible, especially following hospitalizations, emergency department visits, specialist consultations, or medication changes.
Step-by-Step Medication Reconciliation
Review Every Medication
Go through the medication list one medication at a time with the patient.
- Medication name
- Strength
- Dose
- Frequency
- Route
- Whether the patient is actively taking it
Identify Medication Changes
- New medications prescribed elsewhere
- Recently discontinued medications
- Dose changes
- Frequency changes
- Patient self-discontinued medications
- Duplicate therapies
Review Compliance
Document what the patient reports.
- Taking as prescribed
- Missed doses
- Unable to afford medication
- Side effects
- Stopped due to provider instruction
- Stopped independently
Verify Allergies
- Medication allergies
- Reaction type
- Severity if known
- New allergies
- Incorrect allergies requiring provider review
Prepare Provider Review
- Complete documentation.
- Flag discrepancies.
- Notify provider of significant findings.
- Leave prescribing decisions to the provider.
✅ Best Practices
- Review medications directly with the patient whenever possible.
- Include prescriptions, OTC medications, vitamins, and supplements.
- Ask open-ended questions before reading the medication list.
- Document patient-reported information objectively.
- Notify the provider of significant discrepancies before the visit.
⚠️ Common Errors
- Assuming the medication list is correct.
- Leaving discontinued medications active.
- Deleting medications without appropriate documentation.
- Ignoring duplicate medications.
- Failing to review allergies at each visit.
- Documenting provider decisions before they are made.
⬆️ Escalate Immediately
- Potential medication interaction identified.
- Patient reports taking medications differently than prescribed.
- Medication allergy involving a current prescription.
- Patient reports severe medication side effects.
- Recent hospitalization with significant medication changes.
- Controlled substance discrepancies.
Documentation Examples
✅ Good Documentation
Medication reconciliation completed with patient. Patient reports no longer taking Metformin. Currently taking Lisinopril 20 mg daily as prescribed. Added Vitamin D 2,000 IU daily. NKDA confirmed. Provider notified of discontinued medication.
❌ Poor Documentation
Medications reviewed. Everything okay. Updated list.