Medication reconciliation is the process of comparing the medicines a person took before a hospital stay with what the hospital ordered and what the discharge list says, so that omissions, duplicates, wrong doses and interactions get caught. The federal Agency for Healthcare Research and Quality (AHRQ) describes it as reviewing the complete regimen at admission, transfer and discharge and comparing it with the regimen planned for the next setting of care. Families can repeat that check at home with a pharmacist, and this page shows how.
One rule runs through this page: it explains a process and does not say which medicine anyone should take. Nobody should start, stop, skip or change a medicine on their own. Questions go to the prescriber or the pharmacist.
What is medication reconciliation, exactly?
AHRQ’s Patient Safety Network explains that people often get new medicines, or changes to old ones, when care changes hands. Most changes are intentional, but hospital clinicians may not see the full list of what the person took at home, so the discharge list can leave out a needed medicine, repeat a therapy the person already takes, or carry a wrong dose. The World Health Organization’s report Medication safety in transitions of care says such discrepancies affect almost every patient who moves between care settings.
| The list | Where it comes from | What to look for |
|---|---|---|
| Before the stay | The person’s own list, the pharmacy, each prescriber | Everything taken at home, including over-the-counter (OTC) medicines, vitamins, herbal products, creams, drops and inhalers |
| Hospital orders | The hospital team during the stay | What was started, changed or paused in the hospital |
| Discharge list | The discharge papers | What the person is meant to take at home, and a reason for every difference from the first list |
A difference between lists is not automatically a mistake, because a medicine can be stopped or changed on purpose. Every difference should have a reason someone can explain.
Why is hospital discharge a high-risk moment for medicines?
AHRQ notes that these discrepancies put patients at risk of adverse drug events, among the most common kinds of adverse events after discharge. Age adds to it: the National Institute on Aging (NIA) says people 65 and older take more medicines than any other age group, and that more medicines mean more risk of side effects. At home, new bottles join old ones, and two versions of the same medicine can end up on one table.
One honest note: AHRQ reports that pharmacist-led reconciliation prevented discrepancies in reviews, but that reconciliation alone does not reduce readmissions. Treat it as one safety step, not a guarantee.
What should you bring and ask before leaving the hospital?
Medicare’s discharge planning checklist suggests writing down every prescription drug, OTC drug, vitamin and herbal supplement the person takes, noting any changes during the stay, reviewing the list with staff to ask which items and doses to continue, and sharing the updated list with providers. NIA’s guide to taking medicines safely adds that each entry should show the name, amount, times, reason and prescriber, with one copy at home and one in a wallet.
AHRQ’s Be Prepared to Go Home booklet suggests asking the doctor or nurse:
- What medicines do I take when I leave, and is that the same as before I went in?
- What is each medicine for, and when, how and how much do I take?
- What side effects should I watch for, and will it interfere with my vitamins or supplements?
The “brown bag” review is the in-person version. In AHRQ’s Brown Bag Medicine Review, patients bring all prescription and OTC medicines, vitamins, supplements, herbal medicines, topicals, liquids, injections and inhalants, and all pills in their bottles along with any pill organizers. AHRQ says only by seeing the containers and hearing how they are used can a clinician tell whether, and why, medicines are not taken as intended.
How do you do a family medication reconciliation step by step?
This version asks only for lists and questions, never for decisions about the medicines themselves.
- Gather everything in one place. Every bottle, box, blister pack, cream, drop, inhaler and pen, plus vitamins and herbal products, the discharge papers and the person’s list from before the stay.
- Write one master list. One line per medicine: name, strength, how much, when, why, and who prescribed it. The Medicare checklist has a “My drug list” page you can use.
- Compare line by line. Mark each medicine as the same, new, changed, or missing from the discharge list.
- Write down every question. Two bottles with similar names, a medicine that disappeared, a dose that looks different. Do not settle any of these yourself.
- Call the prescriber or the discharge contact. Ask whether each difference was intended.
- Bring the whole bag to the pharmacist. NIA advises using one pharmacy where possible so records sit in one place.
- Update, share and repeat. Correct the master list, give a copy to every provider, and bring it to the follow-up visit. Repeat after any new hospital stay or medicine change.
How do pill organizers and refills fit in?
NIA lists weekly pill boxes, charts, timers and phone reminder apps as ways to take medicines on time, and suggests checking expiration dates and asking the pharmacist for easy-open bottles or larger-type labels if needed.
A sensible order is to finish the reconciliation first, then fill the organizer from the confirmed list. For each new medicine, NIA suggests asking whether a refill will be needed and whether a follow-up visit or test is required first. Ask at discharge, not on the day the bottle runs out.
What if a medicine is new, changed or stopped?
Call the prescriber or the pharmacist. NIA says a person should not stop a medicine because of uncomfortable side effects before talking with a provider, and should not take a larger dose or skip or halve doses to save money. If cost is the problem, say so. For sudden, severe symptoms, use emergency services rather than waiting for a callback.
If a medicine on the list worries you, bring the worry as a question. Our article on medications linked to dementia risk is meant for that conversation with the prescriber, not for removing anything from the pill box. Once a prescriber confirms a medicine was stopped, the FDA says the best way to dispose of most unused medicines is a drug take-back option. See also our medication management guide.
What does Medicare offer: the follow-up visit and the Part D medication review?
| Service | Who provides it | What it can do for medicines |
|---|---|---|
| Transitional care management (TCM) visit | A physician or other qualified practitioner, such as a nurse practitioner | Contact within 2 business days of discharge, a visit within 7 or 14 days, and medication reconciliation and management on or before the visit date |
| Part D Medication Therapy Management (MTM) | The person’s drug plan, through a pharmacist or other qualified provider | A comprehensive review of medicines, a written summary, a “Recommended To-Do List” and a “Medication List” |
The follow-up visit. The CMS booklet Transitional Care Management Services describes a 30-day period that begins on the day of discharge from an inpatient hospital or similar facility, when the person returns to a community setting such as home. Code 99496 requires a visit within 7 calendar days and high-complexity decision making. Code 99495 requires a visit within 14 calendar days and at least moderate complexity. Only one practitioner can bill TCM in the period. When the hospital books a follow-up, ask whether the practice provides TCM, how soon the visit can be, and what it costs.
The Part D review. On Medicare.gov, plans with drug coverage must offer Medication Therapy Management at no cost to people who meet certain requirements. Under 42 CFR 423.153, a plan targets people with multiple chronic diseases (it may require no more than three), multiple Part D drugs (no more than eight) and drug costs above a threshold CMS sets. The yearly review is an interactive consultation with a pharmacist or other qualified provider. If the person cannot take part because of cognitive impairment, the rule allows it to be done with the prescriber, a caregiver or another authorized person. Eligibility differs by plan, so ask the plan.
What can a home health nurse do about medicines?
If the person is homebound and needs part-time skilled care ordered by a provider, Medicare home health can include a nurse. Medicare.gov’s home health page lists patient and caregiver education among the skilled services. The Medicare Benefit Policy Manual, chapter 7, says skilled teaching can include proper administration of oral medication, including signs of side effects and avoiding interaction with other medications and food. A nurse simply giving oral medications is not skilled care unless the condition, drugs and number of drugs require a nurse to detect side effects.
Our Medicare home health benefit guide explains eligibility, and our post-surgery home care page covers the first days home. Our nurse services page lists medication management, including sorting out the bottles that come home from the hospital.
What may a home care aide do with medications in New York?
In New York an aide can help a person take their own medicines, but giving them is a different matter. The line comes from the state’s Medicaid personal care regulation and the Department of Health’s rules for advanced home health aides.
| Task | Who may do it in New York |
|---|---|
| Prompt about the time; identify the medicine, bring it, open the container, position the person, store it | Personal care and home health aides, when the person takes their own medicine. 18 NYCRR 505.14 lists these as personal care functions |
| Observe, record and report changes or problems | The same aides, per the DOH home health aide matrix |
| Give routine, prefilled or packaged medicines to a patient in stable health | Advanced home health aides, a separately certified role, when a New York registered nurse assigns the task in writing, consistent with the practitioner’s orders |
| Prefill medications, calculate doses, decide whether an as-needed (PRN) medicine is needed, give medicines through a feeding tube | Not aide tasks. The Department of Health excludes them even for advanced aides |
The advanced aide rules come from the Department of Health’s FAQ on Chapter 471 of the Laws of 2016 and its 2019 letter to agencies. The letter requires the supervising nurse, before assigning an advanced aide to give medicines, to complete a comprehensive medication review and resolve any discrepancies. An agency also needs the Department’s written approval to offer the service, so ask. The matrix, last dated 2009, adds that steps such as removing the right amount of medicine from the container apply only to a person who is self-directing. For someone with memory problems, ask the supervising nurse. Our guide to home health aide and personal care aide duties covers the rest of the role.
What does the nurse director look for when care starts?
Anna Klyauzova, RN, MSN, MPA, Director of Patient Services at ProLife Home Care, on what she sees in practice:
A registered nurse (RN) from the agency usually does the first assessment. She meets the patient and talks through their health and care needs. She checks whether the person can stand, walk, dress, bathe and use the toilet alone; whether there is a risk of falls, memory problems or disorientation; which conditions and medications affect daily life; how safe the home is; and what family already does. We look closely at what the person can really do, not just what they say they can do.
Talk to a licensed agency in Brooklyn and Queens
ProLife Home Care is a licensed home care agency serving Brooklyn and Queens (NY DOH licence #2572L001). If you are planning the first weeks home after a hospital stay, call (718) 232-2777 or use our contact page to talk through nursing and aide support. Which medicines to take always stays with the prescriber and the pharmacist.
Checked on 14 October 2026 against ahrq.gov, nia.nih.gov, who.int, medicare.gov, cms.gov, ecfr.gov, fda.gov, regs.health.ny.gov and health.ny.gov. This page is general information, not medical advice. Confirm medicine questions with the prescriber or pharmacist, and coverage questions with the person’s plan or 1-800-MEDICARE (1-800-633-4227).
Frequently asked questions
What is medication reconciliation in simple terms?
It is a check of three lists: what the person took before a hospital stay, what the hospital ordered, and what the discharge papers say to take at home. The aim is to catch missing medicines, doubled medicines, wrong doses and possible interactions, and to confirm that each change was intended.
Who does medication reconciliation after a hospital stay?
Hospital clinicians are expected to do it at admission, transfer and discharge, and AHRQ notes that pharmacist-led processes have been studied and can prevent discrepancies. After discharge, the follow-up practitioner is required to provide it on or before the visit if billing Medicare transitional care management. Families can add their own list-and-questions check at home.
What is the difference between medication reconciliation and a medication review?
Reconciliation compares lists across a change in care, such as a hospital discharge. A medication review is a broader conversation about why each medicine is taken and whether it is still needed. Medicare’s Part D program calls its version a comprehensive medication review.
What is a brown bag medication review?
The person brings every medicine in the home to a visit: prescriptions, OTC medicines, vitamins, supplements, herbal products, topicals, liquids, injections, inhalers and pill boxes. AHRQ says every patient should have one once a year, because the containers show what is really being taken.
Does Medicare cover a visit to review medicines after discharge?
Medicare has a transitional care management service for the 30 days after discharge, with a visit within 7 or 14 days and medication reconciliation required on or before it. Part D plans also offer free Medication Therapy Management to people who meet the plan’s criteria. Ask the practice and the plan whether they apply.
Can a home health aide in New York give my mother her pills?
A personal care or home health aide can remind her, bring the medicine, open the container and help her position, when she takes it herself. Giving routine medicines is the job of a specially certified advanced home health aide, assigned and supervised by a registered nurse, working for an agency the Department of Health has approved for that service.
What should I do if the discharge list does not match the medicines at home?
Do not decide which one is right. Write down every difference, then call the prescriber or the hospital discharge contact and bring the medicines to a pharmacist. Do not start, stop or change a medicine until a prescriber confirms what is intended.
