How should a Family Nurse Practitioner (FNP) document medication reconciliation and review of orders in a patient's chart when seeing the patient prior to the Medical Doctor (MD) in a Skilled Nursing Facility (SNF)?

Documentation of FNP Medication Reconciliation Prior to MD Review in SNF

The FNP should document a complete four-step medication reconciliation process in the patient's centralized medical record, clearly identifying their role, date, and any discrepancies requiring MD review, following the standardized framework that includes verification, clarification, documentation, and communication steps. 1

Core Documentation Requirements

The FNP must document the following four essential elements in the patient's chart:

1. Verification Step

• Create a Best Possible Medication History (BPMH) by comparing the facility's current medication list against at least two external sources (discharge summaries, pharmacy records, patient/caregiver interview, or "brown bag" medication review) 1
• Document all medications reconciled including prescriptions, over-the-counter medications, herbals, vitamins/supplements, and medical marijuana with complete details: medication name, indication, dosage, frequency, route, start/end dates 1
• Record allergies, intolerances, and adverse drug events as part of the verification process 1
• Note adherence issues identified during patient/caregiver interview using open-ended questions 1

2. Clarification Step

• Identify and document all discrepancies between the facility medication list and external sources 1
• Flag items requiring MD review with specific notation that these discrepancies need physician clarification or authorization for changes 1
• Document unresolved discrepancies with a clear action plan stating "pending MD review" or similar language 1

3. Documentation Step (Critical for SNF Compliance)

• Record the date and your name/credentials (FNP) as the eligible professional who performed the reconciliation 1
• Highlight changes from the prior medication list to make updates immediately visible to the MD 1
• Document in the centralized medication list location that all providers access, not in scattered progress notes 1
• Note "Unknown" for any data element except medication name (which must always be documented) 1
• Create a tracking mechanism for the action plan on unresolved discrepancies to be addressed during patient care conferences 1

4. Communication Step

• Document that discrepancies have been presented to the MD once the physician reviews your findings 1
• Record the MD's decisions on each flagged discrepancy after their review 1
• Update the centralized medication list with MD-authorized changes and document the MD's name and date of authorization 1

Specific Charting Language for FNP Role

Use clear role delineation in your documentation to distinguish FNP reconciliation from MD order review:

• "Medication reconciliation completed by [FNP name] on [date]. BPMH created using [list sources]. Discrepancies identified and flagged for MD review." 1
• "The following discrepancies require MD clarification: [list specific issues]" 1
• "Pending MD review and order verification before implementation" 1

Critical Compliance Considerations

Medicare Quality Incentive Program Requirements

• FNPs (ARNPs) are eligible professionals to perform medication reconciliation in SNFs under CMS guidelines 1
• Monthly reconciliation is required for all patients with more than seven treatments in the reporting month (though SNFs differ from dialysis units, the standardized approach applies) 1
• The four attestation items must be documented as outlined above to meet quality metrics 1

Common Pitfalls to Avoid

• Never document medication changes as "orders" when you're performing reconciliation prior to MD review—this creates liability and scope of practice issues 2
• Don't leave discrepancies unaddressed—document a specific plan for MD follow-up rather than simply noting the discrepancy exists 1
• Avoid scattered documentation—use only the centralized medication list location to prevent fragmented information during care transitions 1
• Don't skip documentation of your credentials and date—this is essential for quality metric tracking and legal protection 1

Workflow Integration

The optimal sequence for FNP-MD collaboration in SNF medication management:

1. FNP performs comprehensive medication reconciliation using the four-step process within 30 days of admission and monthly thereafter 1
2. FNP documents findings in centralized location with clear flagging of items requiring MD attention 1
3. MD reviews flagged discrepancies and authorizes necessary changes to orders 1
4. FNP or MD updates final medication list with MD-authorized changes, documenting both professionals' involvement 1
5. Updated list is communicated to patient, caregivers, and external providers (primary care, pharmacy) 1

Evidence for Reduced Readmissions

Pharmacist-led medication reconciliation in SNF transitions (which parallels FNP-led reconciliation) demonstrated a 29.8% relative reduction in 30-day readmission rates (14.5% vs. 20.6%) with completion rates exceeding 93% 3. This underscores the importance of thorough documentation by non-physician providers prior to MD review, as the systematic approach itself—not just physician involvement—drives improved outcomes 3.