Medication Reconciliation, Storage, Controlled Drugs and Teaching

Medication Reconciliation and Order Clarification

Medication reconciliation compares a complete medication list with proposed orders at each transition of care, including medications started or changed during a hospital stay when reviewing transfer or discharge orders. This critical process must be performed at admission, during transfer of care between units, and at discharge to prevent unintended omissions, duplications, or dangerous interactions. Within the healthcare team, the registered nurse (RN) conducts the comprehensive initial medication history, while the licensed practical/vocational nurse (LPN/VN) actively assists by collecting and verifying medication data. Any discrepancies identified during reconciliation must be reported promptly to the RN or healthcare provider.

When gathering data, the LPN/VN collects information regarding prescription drugs, over-the-counter medications, vitamins, and herbal supplements. Inquiring specifically about non-oral dosage forms prevents unintentional omissions; clients frequently forget to mention transdermal patches, inhalers, and eye drops unless asked directly. Furthermore, herbal supplements such as St. John's wort, ginkgo biloba, and garlic must be documented thoroughly because of their high potential for drug interactions with conventional therapies.

Data collection regarding drug sensitivities requires precise detail. The LPN/VN documents client-reported drug allergies along with the specific allergic manifestations experienced by the client. The LPN/VN records the client's description of a suspected medication reaction and reports it to the RN so an adverse effect can be distinguished from a true allergy and documented appropriately in the medical record. The LPN/VN holds an unclear, incomplete, or illegible order, reports it to the RN, and ensures the prescribing provider clarifies or corrects the order before administration.