Transitions of Care

Standard 3.0



Perform and Communicate a Medication Reconciliation

Processes are in place to support a reconciled medication list at each care transition point.


Organizations can meet this standard by showing evidence that a comprehensive transition assessment is completed, and that the following elements are included:

Compilation of a full medication history, including both prescribed and non-prescribed medications, from all available sources, including:

  • EHR and discharge summary
  • E-prescribing records
  • Claims data
  • Paper records from other sites of care and providers
  • Self-reported from patient or caregiver
  • Patient’s pharmacy
  • Regular ambulatory care provider

Identification of patients who may be at high-risk for medication related adverse events or non-adherence due to polypharmacy, opioids, high-cost / specialty drugs.

Review of medication history against active medications in the current setting.

Verification of medication list accuracy with patient or caregiver.

Verification of medication adherence with patient or caregiver, and assessment and documentation of any adherence and access barriers, including coverage, affordability, or transportation.

Document all medication reconciliation activities in the medical record, using applicable coding.


Roles & Terms

The treating provider (MD, DO) involved at the time of transition must be the party who is accountable for the reconciliation. The medication review may be performed by a designated clinical team member. The clinical pharmacist is uniquely qualified to make recommendations to optimize medication therapy and avoid potential adverse events such as drug-drug interactions.

Non-licensed providers may gather information but should neither perform medication reconciliation nor provide clinical recommendations.

Ambulatory Care Provider

The care provider who provides regular ambulatory care to a patient outside of an acute or institutional setting. This may be a PCP, ACP or other licensed healthcare provider appropriate to the setting.

Transitions of Care

17200 Chenal Parkway Suite 300 #345
Little Rock, Arkansas 72223

Sponsored by

Funding and support for the Transitions of Care initiative is provided by Pfizer.