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name: langcare-medication-reconciliation description: > Performs comprehensive medication reconciliation across care transitions by comparing inpatient, outpatient, and patient-reported medication lists. Identifies discrepancies including duplicates, therapeutic duplications, dose changes, and discontinued medications. Use when asked to reconcile medications, compare med lists, admission meds, or discharge meds.

Medication Reconciliation

When to Use This Skill

Use when a clinician needs to reconcile medications across care settings per Joint Commission NPSG.03.06.01 -- admission, discharge, or transfer.

Clinical Workflow

1. Use fhir_search to pull active MedicationRequest resources (prescribed orders) with status=active,on-hold
2. Use fhir_search to pull active MedicationStatement resources (patient-reported home medications)
3. Use fhir_search to pull MedicationAdministration resources (inpatient administered medications) filtered by admission date
4. Use fhir_search to pull active AllergyIntolerance and Condition resources for safety cross-reference
5. Normalize all medications to RxNorm codes; build unified comparison table with columns: Medication, Dose, Frequency, Route, Source, Status
6. Identify discrepancies: duplicates, therapeutic duplications (same drug class), dose changes across sources, discontinued meds still listed active, medications with no matching indication, allergy conflicts
7. Flag ISMP high-alert medications (anticoagulants, insulin, opioids, chemotherapy) for extra scrutiny
8. Present reconciliation report and use fhir_update to update MedicationStatement/MedicationRequest status if authorized

FHIR Resources

• MedicationRequest -- Prescribed orders: status, intent, medicationCodeableConcept, dosageInstruction, authoredOn
• MedicationStatement -- Patient-reported medications: status, medicationCodeableConcept, dosage, informationSource
• MedicationAdministration -- Inpatient administrations: status, medicationCodeableConcept, dosage, effectiveDateTime
• AllergyIntolerance -- Drug allergy cross-check
• Condition -- Validate medication indications

FHIR Query Examples

Pull Active Prescriptions

fhir_search(resourceType="MedicationRequest", queryParams="patient=[patient-id]&status=active,on-hold&_include=MedicationRequest:medication&_count=100")

Pull Patient-Reported Medications

fhir_search(resourceType="MedicationStatement", queryParams="patient=[patient-id]&status=active,intended,on-hold&_count=100")

Pull Inpatient Administrations

fhir_search(resourceType="MedicationAdministration", queryParams="patient=[patient-id]&effective-time=ge[admission-date]&_count=100")

Clinical Guidelines

• Joint Commission NPSG.03.06.01: Reconcile medications at every transition of care
• WHO High 5s Medication Reconciliation protocol
• ISMP high-alert medication list for enhanced verification

Interpretation Guide

• Use RxNorm coding (system http://www.nlm.nih.gov/research/umls/rxnorm) for medication matching; fall back to text matching when codes unavailable
• Present findings in categories: Verified Medications (matched across sources), Discrepancies Found (categorized by type), High-Alert Medications (highlighted), Allergy Conflicts, and Recommendations
• For each discrepancy, show both values side-by-side with source attribution

Safety

• Never fabricate clinical data -- only report what FHIR returns
• Flag critical/abnormal values immediately
• Scope all FHIR queries to the authenticated patient
• Use standard terminology (LOINC, SNOMED CT, RxNorm, ICD-10)
• Present data in clinician-friendly format with reference ranges