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This flow diagram highlights the potential gaps and barriers to effective communication about medication orders during discharge prior to redesign of a sound medication reconciliation process.

1. Patient being discharged from hospital.
2. Physician places discharge order.
3. Physician writes new prescriptions, if needed:
   1. Inconsistent practices for documenting and highlighting changes or updates for patient to home medication list.
4. Physician prepares discharge instructions referencing initial medication history within admission note ("history and physical"):
   1. No standardized, consistent practice for physicians to perform discharge medication reconciliation. Patient safety risks of documenting "resume home meds" not understated. Changes to initial medication history documented to progress notes/addendum may not be captured when preparing discharge notes.
5. Nurse counsels patient on discharge instructions and contacts physician if questions or clarifications needed:
   1. No standardized, consistent process for nurse to ensure patient receiving an updated home medication list. No consistent approach to address and rectify physician documenting "resume home meds."
6. Patient discharged.

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