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Medication Reconciliation• Formal and consistent process in which most accurate list of patient’s home medications are compared at transitions of care: admission, transfer, discharge, LTC, homecare
• Discrepancies are identified, brought to attention of physician, required changes are made and communicated
• Intended to minimize potential patient harm from unintended discrepancies
Overview of MedsCheck/Medication Reconciliation Pilot
To facilitate the linkage of the MedsCheck program in community pharmacies with the medication reconciliation process in hospitals in communities across Ontario.
• Community pharmacists BPMH presentations and meetings such as this one
• Sharing teleconferences
11. Transportation
10. Appointment with your surgeon for postoperative follow-up visit
9. Anticoagulation therapy stop date
8. Staples/clip removal date
7. Discharge date from hospital
6. Community Care Access Centre (CCAC) visit or Outpatient Physiotherapy postoperative appointment
5. MedsCheck appointment with your community pharmacist (if you are on 3 or more prescribed meds)
4. Appointments with specialists
3. Appointment with your family doctor
2. Preoperative assessment
1. Date of surgery
DateAppointment/Activity
My Total Joint Replacement Passport
Please use this passport to record the dates for all of your appointments and other activities. The next page explains each appointment / activity in more detail.
My surgeon is Dr. _________________________. His/her office will contact me with my surgery date.
My family member/friend who will assist me throughout my joint replacement is: _______________________.
He/she can be reached at: _________________.
Bring this passport with you to all appointments.
Sample: My Total Joint Replacement Passport
Used with permission from Markham Stouffville hospital
The forms and applications must be completed before your preoperative visit to the hospital. If you have any questions, it is fine to contact your surgeon’s office for assistance.
These forms must be brought with you to your preoperative assessment visit at the hospital:
• History and Physical Form• Anesthesia Patient Questionnaire• Inpatient Rehabilitation Application• MedsCheck from your community pharmacist if you
Translator - If your primary language is not English, please arrange to have a translator with you for all your appointments including on the day of your surgery.
A family member, friend, or caregiver who will be helping you after surgery.
A snack and drink as you will be at the hospital for 4-5 hours; this is particularly important if you have diabetes.
MedsCheck from your community pharmacist if you are on 3 or more prescription medications.
All medications you are taking at home in their original containers with the labels (include prescription eye drops and creams, herbal and over-the-counter medications).
Copies of any recent blood work or diagnostic tests that you have had done outside of Markham Stouffville Hospital.
History and Physical form – completed by your family physician.
The Anesthesia Patient Questionnaire – completed by you.
Rehabilitation Application – completed by you.
The forms given to you with this guide are to be brought in with you to the SAC appointment or returned prior to the appointment. If you have mailed or faxed these forms, you must ensure they reach the hospital before this appointment.
Surgical Assessment Clinic (SAC)
Appointment Checklist
What to Bring with You
Bring this patient guide with you. Your orthopedic team will review your passport with you to ensure
you are completing all of your presurgical preparations correctly.
• Book MedsCheck for pre-admission clinic patients when they ask or if contacted by the hospital
• Perform MedsCheck• Record all the medications the patient is actually taking. If it differs from the prescribed instructions then document the discrepancy in comments section.
• Include all current prescription and over-the-counter medications. (aspirin, iron, potassium)
• Ask about medications dispensed from other pharmacies.
• Perform Follow-up MedsCheck at Discharge within 2 weeks
• Using SPEP students to follow patient from SAC visit to admission
• Using volunteers to phone patients to remind them to get a MedsCheck
• Phoning/faxing pharmacies (with the patient’s permission) to inform them of the patients who are having a surgery and their pre-admission clinic date
• Writing articles in local paper about this new initiative to inform patients
• Faxing community pharmacies a form to fax back so that it is completed in the hospital format as that you would use in hospital. (Note: some community pharmacies are using electronic version)
• Working with community pharmacists on discharge med rec form.