If a patient requires a Best Possible Medication History (BPMH) and/or a Medication Reconciliation (Med Rec) and cannot meet in person, the BPMH/Med Rec can be completed by phone or by a Nova Scotia Health-approved video chat method (i.e. Zoom for Healthcare).
To complete a BPMH and/or Med Rec:
1. Prepare the patient/caregiver
- Work with the patient/family/caregiver explain your role and the purpose of medication reconciliation. Determine who you should speak with regarding the patient’s home medications.
- Ask if the patient/family/caregiver if they are willing to meet by phone or video chat using a Nova Scotia Health-approved video chat method (i.e. Zoom for Healthcare). Request their contact information, and identify the best time to complete the interview.
2. Determine what medication information/sources are available
- Drug Information System (DIS) record
- NSHA and IWK Medication Reconciliation Report
- NSHA and IWK Ambulatory Medication Reconciliation Report
- Community pharmacy record
- Patient medication list, medication vials and/or blister pack
- Medication administration record (MAR) (i.e. from nursing home)
- Hospital pharmacy and/or high cost drug program medication records
- Other medication records if available (i.e. recent outpatient/admission/discharge med rec)
3. Interview patient/family/caregiver
Outpatient medication reconciliation
- For an outpatient medication reconciliation (i.e. ambulatory care clinics) where the patient/caregiver agrees to communicate via a personal device:
- Contact the patient/family/caregiver using a Nova Scotia Health approved phone or a Nova Scotia Health-approved video chat method.
Inpatient medication reconciliation
- For units with Nova Scotia Health phones or video chat enabled devices (i.e. iPads) inside patient rooms:
- Call the patient’s designated phone or dial locating to request to call a patient’s room
OR
- Start a video chat with the patient/family/caregiver via Nova Scotia Health video chat enabled device
- For units without Nova Scotia Health phones/devices inside patient rooms, where the patient/family/caregiver agrees to communicate via personal device:
- Contact the patient/family/caregiver using a Nova Scotia Health approved phone or a a Nova Scotia Health-approved video chat method.
- For inpatients on precautions (i.e. COVID positive) where no phone/device is available, work with the patient’s health care team to relay specific questions during the next direct-care interaction (bundled care approach).
- If the patient/family/caregiver has additional sources of information to share (e.g. medication lists, medication vials, blister pack), request that the patient/family/caregiver send documents via a Nova Scotia Health-approved messaging platform (i.e. Zoom for Healthcare messenger) or email documents or photos to a designated Nova Scotia Health email address (see Electronic Messaging of Personal Health Information Policy and Procedure AD-AO-045).
4. Document the BPMH or Med Rec as per policy
- Ensure all sections of the BPMH/Med Rec form are complete.
- Place the completed BPMH in the patient’s chart/record for review by the health care team.
- In some care areas consider faxing the completed BPMH/ Med Rec to the patient’s community pharmacy and/or primary health care provider, or provide a copy to the patient.
- In outpatient settings you may also need to send the completed BPMH/Med Rec to health records for scanning. This is to ensure that the document is available to other clinicians.
