Verify actual use
Separate prescribed directions from the patient’s real-world pattern, including missed, extra, delayed, or intermittent doses.
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Metropolitan General Health System
PMHNP Clinical Learning Environment
Medication Safety Resource
Medication Reconciliation & Monitoring
Medication reconciliation establishes what a patient is actually taking, compares it with what is documented and intended, resolves discrepancies, and communicates a safe current plan. Monitoring asks whether treatment remains effective, tolerable, feasible, and appropriate as the patient and clinical situation change.
Ask without blame
Normalize differences and barriers so the patient can describe use honestly without fear of being labeled difficult or noncompliant.
Connect medication to purpose
Every medication should have a current indication, treatment target, evidence of benefit, and plan for evaluating harm.
Close the loop
Resolve discrepancies, update the shared record, teach the current plan, coordinate changes, and define follow-up.
Best possible medication history
Use more than one source when possible
No single source is automatically complete. Start with the patient's account, then compare other evidence when accuracy, risk, a care transition, or conflicting information makes verification important.
Patient or caregiver report
Ask the patient to describe what they take in their own words—including doses taken differently, skipped, borrowed, shared, or stopped.
Medication containers and lists
Review bottles, organizers, photos, discharge lists, after-visit summaries, and the patient’s personal list when available.
Pharmacy and controlled-substance data
Use dispensing history, pharmacy clarification, and the applicable prescription drug monitoring program to identify fills, overlap, and discrepancies.
Records and care-team collateral
Compare prior notes, hospital records, laboratory results, medication administration records, and information from other clinicians or supports when appropriate.
For every medication
Capture enough detail to make a clinical decision
“Takes sertraline” is not a usable medication history. Clarify the product, intended directions, actual use, purpose, response, safety, access, and timeline.
Generic and brand name, formulation, route, and strength
Prescribed dose, frequency, timing, and PRN parameters
What is taken, how often, at what time, and in what pattern
Indication understood by the patient and intended treatment target
Benefit, residual symptoms, function, and time course
Adverse effects, allergies, prior reactions, and concerns
Last dose, supply, refills, cost, transportation, and pharmacy
Start date, prior changes, previous trials, and reasons stopped
The full exposure picture
Look beyond the psychiatric prescription list
Prescribed medications
Psychiatric and nonpsychiatric medications from every prescriber, including injections, patches, inhalers, topical products, and PRN use.
OTC products
Pain, sleep, allergy, cold, gastrointestinal, weight-loss, and other nonprescription products that may add risk or alter symptoms.
Vitamins and supplements
Herbal products, vitamins, minerals, performance products, and products marketed for sleep, energy, mood, focus, or weight.
Caffeine and nicotine
Coffee, tea, energy drinks, pre-workout products, vaping, cigarettes, nicotine pouches, and changes in usual exposure.
Alcohol, cannabis, and other substances
Amount, frequency, timing, route, reason for use, withdrawal risk, and overlap with prescribed medication.
Nontraditional access
Borrowed or shared medication, leftovers, online products, samples, compounded products, and medications obtained outside usual care.
Reconciliation workflow
Move from collection to one safe, understandable plan
Collect
Build the most accurate history possible from the patient and other available sources.
Compare
Compare reported use, documented orders, dispensing information, and the regimen intended for the current setting.
Evaluate
Assess indication, response, adverse effects, interactions, adherence, monitoring, and patient-specific risk.
Resolve
Clarify whether each discrepancy is intentional, correct errors, and document unresolved uncertainty rather than guessing.
Communicate
Give the patient and care team one understandable current plan, including what changed, why, and what happens next.
Discrepancy check
Identify what does not match—and why
A discrepancy is not automatically an error. Determine whether it is intentional, clinically appropriate, accidental, or still unresolved.
A medication the patient uses is absent from the record or intended regimen.
The list contains an extra, discontinued, duplicate, or overlapping medication.
Prescribed directions, documented directions, and actual use do not match.
Use differs because of preference, effects, cost, supply, routine, stigma, understanding, or another barrier.
The treatment target is unclear, has changed, or benefit has not been established.
An allergy label, intolerance, side effect, or prior serious reaction is missing, vague, or misclassified.
A medication was started, held, changed, or stopped in another setting without a clear ongoing plan.
Patient report, pharmacy data, records, laboratory findings, or collateral do not agree.
Medication review
Ask seven questions before carrying treatment forward
Why is it being used?
Confirm the current indication and treatment target. Do not carry a medication forward solely because it already appears on the list.
Is it helping?
Assess symptom change, function, patient-defined benefit, time course, and whether an adequate trial actually occurred.
Is it causing harm?
Look for adverse effects, toxicity, withdrawal, activation, sedation, falls, sexual effects, metabolic burden, cognitive effects, and safety concerns.
Does it fit this patient now?
Consider age, pregnancy potential, medical and neurologic conditions, organ function, co-exposures, goals, and preferences.
Can the patient use it as intended?
Explore understanding, cost, access, complexity, beliefs, stigma, swallowing, memory, routine, and support without blame.
What information is still needed?
Identify missing records, collateral, examination findings, vitals, labs, ECG data, levels, scales, or specialist input.
What is the safest next decision?
Continue, adjust, taper, discontinue, defer, consult, or escalate only after the evidence, risks, alternatives, and follow-up plan are clear.
Prior trials
“Tried before” is the beginning of the history
A prior medication cannot be interpreted without the dose, duration, adherence, target, response, adverse effects, reason for stopping, and what happened afterward. A brief exposure, unaffordable prescription, intolerable reaction, and adequate ineffective trial mean very different things.
- Who prescribed it, and for what target?
- Was the dose and duration adequate?
- Was it taken consistently enough to judge?
- What improved, worsened, or remained unchanged?
- Why was it stopped, and who made that decision?
- Would retrying it repeat a known risk or barrier?
Psychiatric medication monitoring
Match monitoring to the medication and the patient
Monitoring begins before a change and continues after it. Use the current product label, evidence-based guidance, the patient's conditions and co-exposures, and the care setting to determine exact measures and timing. These are clinical prompts, not a complete protocol.
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Antipsychotics
Track response, weight and metabolic health, blood pressure, movement symptoms, sedation, orthostasis, sexual or prolactin-related effects, and medication-specific risks. Use structured movement assessment when indicated.
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Lithium
Verify formulation, dose and level timing, renal and thyroid status, calcium, hydration and sodium changes, interacting medications, pregnancy considerations, and symptoms of toxicity.
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Anticonvulsant mood stabilizers
Review medication-specific hepatic, hematologic, dermatologic, metabolic, reproductive, interaction, and serum-level considerations. Do not treat different agents as interchangeable.
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Antidepressants
Monitor target symptoms, suicide-related change when relevant, activation or emerging mania, anxiety, sleep, sexual effects, bleeding and sodium risks, discontinuation symptoms, and serotonin toxicity.
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Stimulants and related ADHD medications
Review blood pressure, pulse, appetite, weight or growth, sleep, mood activation, cardiovascular history and symptoms, early refills, misuse, diversion, and substance exposure.
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Sedative-hypnotics and benzodiazepines
Assess sedation, cognition, falls, driving, respiratory risk, alcohol or opioid exposure, tolerance, dependence, withdrawal risk, duration, and controlled-substance history.
Escalation
Pause the routine review when toxicity or serious harm is possible
A medication visit can become an urgent medical or psychiatric evaluation. Stabilization, consultation, testing, a higher level of care, or emergency response may take priority over the planned discussion.
- New severe confusion, ataxia, slurred speech, marked tremor, or another possible sign of medication toxicity
- Fever with rigidity, autonomic instability, altered mental status, or rapidly progressive movement symptoms
- Severe rash, mucosal involvement, facial swelling, breathing difficulty, or another serious hypersensitivity concern
- Profound sedation, slowed breathing, syncope, chest pain, or concerning cardiovascular symptoms
- Severe agitation, emerging mania, abrupt behavioral change, or worsening suicide-related thoughts after a medication change
- A high-risk pregnancy or reproductive-safety issue requiring prompt medication-specific consultation
Medications reviewed. Patient is noncompliant. Continue current regimen and monitor.
Patient reports taking sertraline 50 mg on approximately four mornings per week rather than daily because of nausea and an irregular work schedule; pharmacy history is consistent with delayed refills. Reports modest improvement in worry but persistent low mood and no clear activation. Also uses diphenhydramine most nights, two energy drinks daily, and cannabis on weekends for sleep. Discussed how inconsistent dosing and co-exposures limit interpretation of response. Plan addresses nausea and schedule barriers, sleep treatment, interaction concerns, an updated medication list, and reassessment after a defined interval.
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Shared decisions and coordination
End with a plan the patient and care team can use
Explain what continues, changes, stops, or remains uncertain; why; how the medication should be used; which warning signs require action; what monitoring is needed; and when follow-up occurs. Use teach-back, provide an updated list, and communicate material changes to the care team as appropriate.