Reconciling Medications for Discharge

When preparing a patient for discharge from the hospital, Commure Pro Mobile Medication Reconciliation has a discharge process that allows you to review and take action on the patient’s past and present medication orders which includes home medications (stopped, continued, and changed home medications) and hospital only medication orders. It also allows you to add new discharge orders.

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Starting Mobile Discharge Medication Reconciliation

To begin the process of stopping, continuing or changing a patient’s medications orders or adding other discharge orders:

1. From the Patient List screen, select a patient.
2. When the View Modules list displays, select Orders. The Orders module displays.
3. Select the Orders drop-down menu at the top of the screen, and then select Discharge Med Rec from the list. The Discharge Med Rec screen opens and displays a list of medications to reconcile for discharge. The most recent visit is selected.

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Submitting Discharge Orders without any Home or Hospital Medication Orders

If a patient does not have any home medications or hospital medication orders to reconcile for discharge, you can still enter new discharge orders and submit them within the Discharge Med Rec screen.

1. Tap Add at the top right corner to add discharge orders within the Discharge Med Rec screen (see Adding a Discharge Order).
2. Tap Sign & Submit to reconcile and submit any discharge orders, if added. See Reconciling All Discharge Orders. If there are no warnings or alerts to resolve, your reconciliation is complete. If there are warning and alerts to resolve, go to the next step.
3. Review and resolve any medication interaction warnings and alerts (see Reviewing Interaction and Duplicate Order Alerts), and then resubmit the orders.

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Reconciling Medication Orders for Discharge

You must reconcile all hospital medication orders and home medication orders before discharging the patient. However, if enabled, you can choose to do a partial reconciliation of medication orders for discharge (check with your administrator). You may also add other discharge orders such as physician consults. You need to complete the following procedure to reconcile all the medications:

• Modify or add any orders for discharge. You will see a warning message stating “Visit has a Finalized Med/Discharge Plan in MT. Please see MT for full set of Discharge Orders.” Select Dismiss and you will exit the Discharge Med Rec screen, or
• View the list of finalized discharge orders. If you cannot see the finalized list, you can review them in MEDITECH.

1. Review all medications (home and hospital) that need to be reconciled in the MEDICATIONS TO RECONCILE section (See Reviewing All Medication Orders) and any existing discharge orders (See Reviewing Existing Discharge Orders).
2. Choose a course of action for each medication that needs to be reconciled. See Choosing a Course of Action for Discharge. If you are doing a partial medication reconciliation, only select a course of action for the medications that you wish to reconcile. If your patient does not have any home or hospital medications, you will see the message: The selected visit does not have any medications to reconcile under the MEDICATIONS TO RECONCILE section.

While you decide the course of action for each home medication or hospital medication, you can also choose to do the following:

• (Optional) Remove a home medication if mistakenly entered. See Deleting a Home Medication.
• (Optional) Add a new discharge order. See Adding a Discharge Order.
• (Optional) Delete a new or existing discharge order. See Deleting a Discharge Order.
• (Optional) Modify a new discharge order. See Modifying a New Discharge Order.

3. Reconcile and submit discharge orders. See Reconciling All Discharge Orders.
4. Review and resolve any medication interaction warnings and alerts. See Reviewing Interaction and Duplicate Order Alerts.

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Reviewing All Medication Orders

The Discharge Med Rec screen displays all current medication orders including home medications and any hospital medication order in the Medications to Reconcile sections. Icons are used to signify the status of the medication orders as follows: Unreconciled home medication that was stopped upon Admission. Unreconciled hospital medication orders. If a home medication was continued as a hospital order, you will see both the unreconciled home medication and unreconciled hospital order displayed together. You can view the list of medication orders in one of two ways:

• Grouped by Home Medications and Hospital Only Medications with the Group By Type selected (default) located in the MEDICATIONS TO RECONCILE header.
• Listed in alphabetical order by the medication name if Group by Type not selected.

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Reviewing Existing Discharge Orders

If the patient visit has any existing discharge orders that were either submitted and reconciled from your back-end EHR or previously reconciled within Commure Pro, these orders will display as follows:

• Reconciled home or hospital medications will display in the PREVIOUSLY RECONCILED section by the name of the provider who submitted the reconciliation. Tap the provider name to display the reconciled medication orders.
• Reconciled additional discharge orders will display in the ADDITIONAL DISCHARGE ORDERS section. The order icon will display without the add symbol to denote that it is reconciled. You can delete these orders if desired by swiping right-to-left, and then selecting Delete.

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Choosing a Course of Action for Discharge

Before you can complete the reconciliation of medication orders for discharge, you must decide to either stop, continue, or change every home and hospital medication order. You cannot complete the reconciliation process until every medication order has a course of action unless your facility allows you to submit a partial medication reconciliation (check with your administrator). The MEDICATIONS TO RECONCILE section displays a list of unreconciled home and hospital medications with a yellow caution symbol (displayed as a yellow exclamation mark). Any unreconciled medication that you choose to continue or change will become a discharge order when you complete the reconciliation.

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Stopping a Medication Order for Discharge

If you determine that a home medication or a hospital medication is not required for discharge, you can choose to stop it as follows:

• Tap Stop located next to the home medication.

The Stop icon turns red . If you stopped a home medication in error, you can undo the Stop order action as long as you do so prior to submission for reconciliation. You can undo the Stop order action in one of the following ways:

• Tap the red Stop to return it to the unselected state.
• Use the right-to-left swipe on the home medication row, select More , and then select Reset from the menu options.

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Continuing a Medication Order for Discharge

You can continue the home medication or hospital medication as a discharge order if there are no changes required.

1. Tap Continue/Change in the home or hospital medication row, and then select Continue.

If the order is complete, the Continue/Change icon turns green and the discharge order displays under the original home or hospital medication with the prefix New: and the New Discharge Order icon . The order is then ready for reconciliation. If either the Order Search window or Order Details window displays, proceed to the next step.

2. If the Order Search screen displays, your order does not have a valid route or a matching order. You must select the correct medication in the search results. If the Order Details screen appears, there are CDS alerts or you have missing required information. Review any CDS alerts and complete any highlighted required information, and then tap Save.

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Changing a Medication Order for Discharge

You can modify the medication order or choose a different medication for inclusion as a discharge order.

1. Tap Continue/Change in the home or hospital medication row, and then select Change.

The Order Search window displays any possible matching Formulary (including matching medications in the same therapeutic class) and Non-Formulary (if enabled) medications. You now have the ability to either change to a different medication in the same therapeutic class or modify the existing medication.

2. Select the desired medication, using one of the following ways:
   • To modify one or more of the details of the existing home medication, select the same medication with the desired changes from the list of search results; or
   • To change to a medication in the same therapeutic class, select the desired new medication from the list of medications.

If you select a medication that has all the required information completed, the Continue/Change icon turns green**** and the discharge order displays under the home medication with the prefix New: and the New Discharge Order icon .displays. The order is then ready for reconciliation. If the Order Details screen displays, proceed to the next step to complete your changes.

3. Review any CDS alerts and enter any changed or new information into the Order Details window, and then tap Save.

The Continue/Change icon turns green**** and the discharge order displays under the home or hospital medication with the prefix New: and the New Discharge Order icon displays. The order is then ready for reconciliation.

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Deleting a Home Medication

If you discover that a home medication was incorrectly entered, you can remove it as follows:

• Use the right-to-left swipe on the home medication, and then select Delete . The home medication displays with Delete: in the list. You will need to submit the change to get the home medication removed from the list.

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Adding a Discharge Order

You can add more medication orders to your patient’s list of Discharge Orders. You may also add new non-medication orders or order sets. You can add a new non-medication order or use free text to add an order that isn’t found using the search function.

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Adding a New Discharge Order

To add any type of new order to the list of Discharge Orders:

1. Tap Add at the upper right corner of the Discharge Med Rec screen. The Order Search screen displays.
2. Select an order from your list of Favorites or enter the name of the order, and then select the order from the search results. If the Order Details screen displays, review any CDS alerts and complete any missing fields.

Tap Save to add the order. The selected order has a check next to it.

3. Tap Review (n) in the upper right corner of the screen to review the added order in the Discharge Med Rec screen.

The added hospital order displays in the ADDITIONAL DISCHARGE ORDERS section under the MEDICATIONS TO RECONCILE section with a new order icon specific to the type of order added. The order is ready for reconciliation unless a warning or an alert needs resolution.

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Using Free Text to Add a Discharge Order

If you do not find any matches for your order using the Search function, you can choose to add it as a free text order if your system is enabled with this capability as follows:

1. From the Search screen, the name of the entered order with the description Free Text or Free Text Medication (if you entered a medication order) displays. Select this order. If the order is a generic Free Text order, choose the order type. The following happens:
   • If you added a Free Text order, it is added to the ADDITIONAL DISCHARGE ORDERS section in the Discharge Med Rec screen. The order is ready for reconciliation unless you need to make changes. If you need to make changes, you will need to select the order to display the Order Details, and then proceed to the next step.
   • If you added a Free Text Medication order, the Order Details screen displays, proceed to the next step.
2. Enter the desired information into the available fields including any required fields, and then tap Save. The new order is added to the ADDITIONAL DISCHARGE ORDERS section in the Discharge Med Rec screen. The order is ready for reconciliation.

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Deleting a Discharge Order

If you decide you no longer need a new discharge order (prior to submitting it) or an existing discharge order under the ADDITIONAL DISCHARGE ORDERS section, you can delete the order as follows:

• Use the right-to-left swipe on the home medication, and then select Delete . If you deleted a new discharge order, it is removed from the Discharge Med Rec screen. If you deleted an existing discharge order, it displays with Delete: in the ADDITIONAL DISCHARGE ORDERS section. You will need to submit the change to get the order removed from the ADDITIONAL DISCHARGE ORDERS section.

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Modifying a New Discharge Order

If you need to change any of the unsubmitted new discharge orders, you can modify the order as follows.

1. Select the new discharge order listed from either the MEDICATIONS TO RECONCILE section or the ADDITIONAL DISCHARGE ORDERS section. The Order Details screen displays.
2. Review any CDS alerts and make any desired changes, and then tap Save. The modified order displays under the MEDICATIONS TO RECONCILE section or the ADDITIONAL DISCHARGE ORDERS section with the modified information. The order is ready for reconciliation.

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Reconciling All Discharge Orders

After you have decided upon an action for the home medications and existing hospital medications and added any new discharge orders you are ready to complete the reconciliation process. After you tap Sign & Submit , you may be required to enter your Commure Pro password or a numeric PIN (Personal Identification Number). Or, if Apple’s Touch ID® or Face ID® feature has been set up on your device (see Establishing a Touch ID or Face ID for Logging In or Signing Orders), and has also been enabled by your administrator, you can use your fingerprint to sign your orders instead of a manually entering a password or PIN. Depending on how your administrator has configured the system, any one of the following scenarios may apply:

• You are never required to enter a password or PIN (or to use Touch ID or Face ID) after you select the Sign & Submit button.
• You are required to enter a password or PIN the first and every time that you select the Sign & Submit button. If Apple’s Touch ID or Face ID feature is enabled on your device, after you enter your password or PIN the first time, you are then prompted to use the Touch ID or Face ID feature (instead of password or PIN) each time you select the Sign & Submit button.
• You are required to enter a password or PIN the first time you select the Sign & Submit button, and then the application “remembers” your this information for subsequent submissions in the same session. You are not required to enter it again unless you have a period of inactivity (no new order submissions) that is longer than a specific period of time defined by your administrator. Again, if Apple’s Touch ID for Face ID feature is enabled on your device, after you enter your password or PIN the first time, you are then prompted to use the Touch ID/Face ID feature (instead of password or PIN) whenever you have a period of inactivity that is longer than the defined time.

• In addition, your administrator may require you to enter the name of a provider who can co-sign the orders for you. This feature can be enabled for all orders, or just certain types. To sign and submit all your new orders for a given patient, follow the steps below.

1. On the Discharge Med Rec screen, tap Sign & Submit .
   If a message displays that discharge orders may not be submitted, then the admission order entry process may be incomplete. For Medicare patients with an inpatient visit, a signed admission order is required in order to submit discharge orders and complete Discharge Med Rec. Check the admission order for the patient to ensure a signed/authenticated order exists.
2. If not all the home or hospital medications have an action, a pop-up displays asking if you want to stop the remaining medications or if you want to submit a partial reconciliation (must have partial reconciliation enabled at your facility). Select Stop Remaining Meds or Submit Anyway (partial reconciliation).
3. If an additional password, PIN, or co-signing provider are required, the Signature screen is displayed, containing one or more of the dialogs below is displayed. Complete each screen as follows, depending on what it requires:
   • Manual Entry of Password or PIN: Manually enter your password or PIN, and then tap Done.
   • Manual Entry of Password or PIN, plus Co-Signing Provider: Manually enter your password or PIN, and then enter the name of the co-signing provider (using the Search field or the Recently Selected list), and then tap Done. If only one provider can co-sign for you, that name is defaulted into the field for you.
   • Touch ID or Face ID in place of Password or PIN: If Touch ID or Face ID is enabled (and your Touch ID/Face ID has been established via Establishing a Touch ID or Face ID for Logging In or Signing Orders), then immediately after you tap Sign & Submit one of the following dialogs is displayed:
   • For Touch ID: “Touch ID for Commure Pro. Sign using your fingerprint.” Press your finger lightly on the Home button to register your fingerprint and immediately sign your orders. If your fingerprint is not accepted for any reason, a Sign using pin/password option is automatically displayed. If you select this option, the Password or PIN field is shown. Enter your password or PIN and then tap Done. - For Face ID: The Face ID logo is shown. Show your face to the front camera to register your identity and immediately submit your orders. If your facial image is not accepted for any reason, a Try Face ID Again option is automatically displayed. Select the option and try again. Or tap Cancel, tap into the Password or PIN field, enter your password or PIN, and then tap Done.

• Co-Signing Provider: If a password or PIN are not required, or if you used Touch ID/Face ID in place of manually entering the password or PIN, you may next see a dialog asking for the name of the co-signing provider. Enter their name using the Search field or the Recently Selected list, and then select Done. If only one provider can co-sign for you, that name is defaulted into the field for you. Each of the patient’s new orders are now checked for interactions or duplicates.
• If none are found, the order is submitted to the server and moves to the Existing Orders section. If you were required to enter a co-signing provider, the orders are then routed to the co-signing provider for signature, and they are also added to the patient’s Existing Orders list.

• If the order has errors, an alert or warning describing the error is displayed. You can correct the issue and submit again, or you can discard the order. See Reviewing Interaction and Duplicate Order Alerts.

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Understanding Unsubmitted Orders

A patient’s new orders accumulate either in the Home Medications to Reconcile or Additional Discharge Orders section until you sign and submit them. If your device is not connected to the server at the time that you select the Sign & Submit button, or if you exit the Discharge Med Rec section of the Orders module without selecting the Sign & Submit button, the new orders are not submitted. The orders remain on your device as long as you do not discard them. There are multiple safeguards in place to ensure that you do not forget to submit these orders. Please note that in all cases below, the application notifies you about only those new unsubmitted orders that you created on this mobile device. Unsubmitted orders that you created on a different mobile device or on the desktop Medication Reconciliation application are not included.

• Yellow Caution Symbol: For each patient that has new unsubmitted orders, an exclamation mark highlighted in yellow is displayed next to the patient’s name on the Patient List, to highlight that fact. You can submit the orders when you are ready, by going to the Discharge Med Rec section of the Orders module for that patient and tapping the Sign & Submit button. Or, if you decide you do not want to submit the orders after all, you can tap the Discard All button to discard all the new unsubmitted orders.
• Numeric Red Badge on the Pending Button: If you have one or more unsubmitted orders for any of your patients, the Pending button (located in the bottom tool bar of the application) will have a red badge with a number:. This number indicates the total number of your unsubmitted orders, draft notes, and unsigned documents. Tap the Pending button to view the Notifications screen. If the Unfinished Orders item has a number after it, such as Unfinished Orders 3, this indicates the number of unfinished orders. Select the Unfinished Orders option to view the Unfinished Orders screen, which displays a list of all your unsubmitted orders, sorted by patient. Under each patient’s group of orders, there are two options:

• : Tap Go to Orders to go to the Discharge Med Rec section of the CPOE Orders module for this particular patient, where you will see the unsubmitted orders listed in the Home Medications to Reconcile section and any unsubmitted orders in the Additional Discharge Orders section. You can then modify, sign and submit, or discard the orders.
• : Tap Discard All to discard all of the unsubmitted orders for this patient.
• Text Alert when Logging Out: If you log out of Commure Pro while you still have unsubmitted orders, the following warning message is displayed: “You have [n] unsubmitted orders. Are you sure you want to log out?” You are then presented with options to keep the orders and log out, discard the orders and log out, or cancel logging out. If you keep the orders and log out, you will not receive any text notifications about them. However, the unsubmitted orders will remain on the device (flagged with the yellow icon until you log back in again and either submit or discard them.
• Text Alert when the Device Times Out: If the Commure Pro application times out while you have unsubmitted orders, a single text notification is displayed after five minutes to remind you that you have unsubmitted orders. Launch the Commure Pro application, and as described above, the patients with unsubmitted orders will be flagged with the yellow icon so that you can quickly identify them and address their orders. Or you can ignore the message; the unsubmitted orders will remain on the device (flagged with the yellow icon until you log back in again and either submit or discard them.

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Reconciling Additional Medication Orders after Completing Discharge Medication Reconciliation

If your patient should need additional medications for discharge added after you submitted and reconciled them, you can return to the Discharge Med Rec screen and reconcile these additional home medications as follows:

1. Start the Discharge Medication Reconciliation process as described in Starting Mobile Discharge Medication Reconciliation.
2. Reconcile the additional medications as described in Reconciling Medication Orders for Discharge.