Clinical Basis

As one of the four-parts in the Transitions of Care measure, medication reconciliation is a critical part of post-discharge care coordination for all patients taking prescription medications. Patients who have more than one chronic condition are likely to take more medications; therefore, ensuring proper medication reconciliation is imperative to preventing unintended complications.1


It is a best practice to conduct the medication reconciliation within seven days of discharge.

Coding and Documentation Guidance


Hospital Best Practices

Promptly send PCP a discharge summary containing a list of discharge medications. The Joint Commission identifies five steps in the medication reconciliation process:

  1. Obtain a list of out-patient medications.
  2. Obtain the list of medications prescribed at discharge.
  3. Compare the medications on the two lists.
  4. Make clinical decisions based on the comparison.
  5. Communicate the new list to appropriate caregivers and to patients.

Group Best Practices

Prior to discharge, schedule a PCP appointment with patients within seven days:

  • This is the best time to do medication reconciliation.
  • The reconciliation may be conducted by a PCP, NP, PA, RN or clinical pharmacist and may be done telephonically.

PCP Best Practices 

  • Document the reconciliation in the outpatient medical record with an appropriate chief complaint, such as “post-discharge hospital follow-up.”
  • Include a dated progress note stating “Hospital (or skilled-nursing facility) discharge medications were reconciled with the current outpatient medications.”
Be sure to include a signed and dated list of current medications.

1 National Quality Measures Clearinghouse (NQMC). Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2015 Oct 01. [cited 2016 Nov 15] Go to https://qualityindicators.ahrq.gov/ for additional information.

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