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How to Complete a Medication Reconciliation

The Medication Reconciliation List Page allows for you to record if a patient is taking a medication and record adherence. This page will pull from SmartCare’s Rx Module and CalMHSA Rx. Anyone who has access to these screens/modules will be able to view all client medications.

Note: It will only pull in medications that are active and/or have End Date that is ≤ 90 days.   

Limitations:

  • The information is only stored once. If a user overrides the medication reconciliation, then historical information is not stored.   
  • You may find duplicate medications in case they are ordered on >1 Rx platforms e.g.,  Medications from SmartCare Medication Management Rx and CalMHSA Rx for the same client will be pulled into the list page and there may be duplicates in these.  

Permissions: The following roles will be allowed to add/edit: 

  • Medication Rx 
  • Prescriber 
  • Add Medication Prescribed Elsewhere 
  • Add Pharmacies to Rx 
  • Allergies and Flowsheet 
  • Prescriber Medical IP/CSU/Res 
  • Nurse Medical IP/CSU/Res 
  • Medical Supervisor 
  • County Affiliate Sys Admin 
  • CalMHSA Sys Admin 
  • Medical Records/Quality Assurance 
  • SUD Add-On 

To begin follow the steps below: 

  1. Click the Search icon, with the Client Open. 
  2. Type Medication Rec into the Search bar. 
  3. Click to select Client Medication Reconciliation List Page (Client)
  1. The Client Mediation Reconciliation List Page will open. The mediations from the Rx Modules i.e. Medication Management Rx in SmartCare and CalMHSA Rx will be pulled into the list page automatically. 

This List Page contains following columns that derive data from respective Rx screens – 

    1. Med Name – Name of Medication as entered in the Rx modules 
    2. Quantity- This pulls data as entered in ‘Dose’ from SC Medication Management Rx, ‘Quantity’ of units from CalMHSA Rx.  
    3. Form- Dosage Form, Abbreviation (Tablet, Cream, Syringe) 
    4. Route- Dosage Route Abbreviation (Oral, Top [topical], etc.) 
    5. Schedule- Schedule/Frequency
    6. Special Instructions-   For CalMHSA Rx this is pulling the data that is entered in the in the field for “Additional Directions To Patient”  and for medication Rx it is from “Desired Outcome”.
    7. Start & End Dates: Start Date is pulled from respective Rx modules. For End Date, once user clicks into the medication name,  the information on the medication being actively taken and the date last taken can be updated.    
    1. Taking Med- Yes or No based on documentation in the Client Medication Reconciliation Detail screen
    2. Date Last Taken – based on documentation in the Client Medication Reconciliation Detail screen
    3. Comments-based on documentation in the Client Medication Reconciliation Detail screen
    4. Reconciled By– Name of User If not input, then it is displayed as N/A 
    5. Reconciled Date- Date when client medication reconciliation list page is opened.  
Note: The first time that the medication reconciliation page is opened by an end user, the “Last Reconciled Date”, will generate as the current date. The “Reconciled By” will be N/A until a user inputs data.
  1. Click the Mediation hyperlinked name.
  1. In the Medication Reconciliation Questions section, click the Actively Taking Medication radio button for Yes, No or Unkown (this is a required field). Enter the date last taken if known and add any necessary comments.
  2. Click Save. 

The List Page will now display the information. 

If you would like to review a medication list within your note, we recommend using Keyphrases. For more information on this, CLICK HERE. 

  • Last Updated: April 17, 2025