Medication management and reconciliation

Status: DETAILED MEDICAL OPERATING SOP DRAFT — human-readable clinical workflow; not yet clinically or operationally approved

Public service anchor: CMS GUIDE RFA Appendix B §§7.1-7.5 ↗. Transition medication work also appears in Appendix B §5.4. The Proxi column identifies candidate automation, not functionality already deployed. The acquired Participant's current executed agreement still needs to be checked before operations are finalized.

Medical SOP purpose and clinical boundary#

This SOP defines how Proxi obtains the best available medication history, preserves each source's claim, compares discrepancies, obtains prescribing-authority reconciliation, coordinates any medication change, communicates an authorized regimen, confirms understanding and practical implementation, and monitors the result.

Medication reconciliation is not selection of the newest or most authoritative-looking list. It is the prescribing-authority clinician's comparison of the best available medication history with current orders, treatment plans, transition information, reported use, supply evidence, allergies and reactions, symptoms, and unresolved questions, followed by an explicit determination of the intended regimen and disposition of every material discrepancy.

The following remain separate even after reconciliation:

• Clinician-intended regimen: what the authorized clinician currently intends the beneficiary to use.
• Order or prescription: the legally valid request issued by an authorized prescriber.
• Transmission and pharmacy response: whether the order or cancellation reached the pharmacy and how the pharmacy responded.
• Dispense or handoff: what the pharmacy or facility actually supplied or handed over.
• Possession: what appears to be present and accessible to the beneficiary, caregiver, or facility.
• Reported use: what the beneficiary or caregiver says is being used, stopped, skipped, changed, or refused.
• Administration: a documented dose actually administered in a facility or by another person.
• Unresolved source assertion: a material fact that remains missing, ambiguous, stale, or conflicted.

Reconciliation does not prove that the beneficiary obtained, understood, or implemented the intended regimen. Likewise, a claim does not prove dispensing, a dispense event does not prove possession, and possession does not prove use.

Order does not prove transmission; transmission does not prove pharmacy acceptance; acceptance does not prove dispensing; a claim does not prove handoff; dispensing does not prove possession; possession does not prove use; and reported use does not prove administration.

CMS RFA §§7.1-7.5 establish the public GUIDE obligations. The detailed interview dataset, discrepancy method, teach-back, monitoring plan, and closure criteria below are Proxi clinical operating design informed by AHRQ MATCH and RED medication-safety guidance; they are not additional CMS requirements.

Monthly monitoring is not monthly reconciliation#

CMS RFA §7.1 requires prescribing-authority review and reconciliation at the comprehensive initial assessment, at future assessments, and periodically when requested by the care team, beneficiary, or caregiver, as appropriate. It does not require monthly reconciliation.

Keep these activities and outcomes separate:

A real no-change reconciliation exists only when the prescribing-authority clinician reviews sufficiently current evidence, disposes every material discrepancy, and explicitly concludes that the intended regimen remains unchanged. “No new claim,” “no source delta,” and “no change reported” do not mean the same thing and do not become reconciliation. Do not create a separate medication contact or clinician review solely because the billing month is otherwise empty.

Proxi supplies or contracts the assigned labor under the validated Participant and Partner Organization arrangement. The enrolled GUIDE Participant retains nondelegable responsibility for the Section 7 service, care-team supervision, clinical quality, disclosure controls, and supporting evidence. External prescribers, pharmacies, facilities, and emergency services retain the clinical, dispensing, administration, or emergency acts only they can furnish.

Authority and role assignment#

The Puerto Rico L2 navigator operation performs no licensed assessment, triage, reconciliation, recommendation, prescription, deprescribing act, treatment decision, or individualized clinical instruction. Every such act routes to the separate U.S. clinical workforce. Before that professional acts, confirm the beneficiary's current physical location and the professional's current authority for that jurisdiction and act. If location or authority is unknown, L0-L2 may gather facts and connect the person, but no clinical decision or new instruction occurs through that route. Immediate safety connection is not delayed for routine intake.

Cross-pillar preparation, no-repeat handoffs, owner acceptance, and shared labor follow 25_GUIDE_Eight_Pillar_Service_Integration.md. A source-separated prepared medication question routes directly to the beneficiary-location-authorized prescribing or other qualified clinical owner; Puerto Rico L2 is never the clinical gateway.

Triggers and required clinical owner#

Minimum medication-history dataset#

For every prescription medication, OTC product, vitamin, supplement, herbal or natural treatment, sample, compounded product, and other substance, obtain as much of the following as the sources support:

• verbatim product name and any source code or image;
• ingredient or product identity only to the specificity actually supported;
• strength or concentration, dosage form, route, amount per dose, frequency, times, duration, and effective dates;
• PRN indication, conditions, interval, and maximum when prescribed or documented;
• taper, cross-titration, alternating-day, multi-strength, conditional-hold, split-tablet, device, or other complex directions;
• indication or purpose as documented by a clinician and as understood by the beneficiary, without converting a lay report into a diagnosis;
• prescribing or recommending clinician, practice, and treatment relationship;
• order, prescription, stop, cancel, dispense, reversal, administration, and transition sources with event and receipt dates;
• whether the item is reportedly possessed, placed in packaging or a pill organizer, used, missed, refused, self-changed, stopped, or administered, including last known dose when clinically relevant;
• pharmacy, facility, mail-order, sample, cash, caregiver, or other supply route and available quantity or days supply;
• reported benefit, problem, symptom, fall, confusion, sedation, swallowing or device difficulty, cost, coverage, shortage, transport, packaging, or other access barrier;
• who organizes, reminds, assists, or administers the medication and what schedule support is currently used; and
• source, reporter, observation time, record time, confidence limitation, correction, and unresolved conflict.

Medication allergies, intolerances, and prior adverse reactions are collected as a separate clinical record. Capture the product, reaction as reported, timing and severity when known, reporter, and source. A vague report is not automatically promoted to a confirmed allergy, and a contradictory “no known allergies” record does not erase it.

No source wins by default. EHR lists, pharmacy claims, bottles, discharge paperwork, facility records, beneficiary reports, and caregiver reports each establish only what that source can prove.

Universal medication-safety bypass#

When any person reports a possible overdose, wrong medication or dose, acute symptom, fall, confusion, sedation, allergic-type reaction, missed critical therapy, self-change, administration error, or request for urgent medication advice:

1. The first human responder confirms identity, callback number, current physical location, medication or substance involved, what was taken or omitted if known, last known dose when safely obtainable, symptoms or event, onset and timing, and actions already taken.
2. The responder records the report verbatim without assigning causality, severity, urgency, or treatment.
3. Immediate danger invokes the approved emergency pathway without delaying for a complete history. Otherwise, connect the beneficiary or caregiver to the beneficiary-location-authorized RN, prescribing clinician, or other approved clinical professional.
4. L1/L2 does not advise starting, stopping, holding, repeating, crushing, splitting, substituting, or changing medication unless relaying an exact instruction previously authorized for that exact situation.
5. Failed connection remains an active escalation. Record who accepted the handoff, the clinical disposition and instructions, emergency action, unsuccessful attempts, and the resulting reconciliation, communication, or monitoring work.
6. Completing a safety handoff does not itself complete medication reconciliation or prove the medication caused the event.

Detailed medication review and reconciliation procedure#

1. Confirm identity, location, participation, and authority. Verify the beneficiary, current physical location and care setting, respondent identity, beneficiary participation, caregiver or representative role when relevant, preferred language, accessibility needs, and the proposed clinician's authority.
2. Build the source-faithful reported-use history before navigator or clinician time. Software presents the source-separated candidate list through an accessible structured text, voice, photo, or assisted intake and asks the beneficiary/caregiver to confirm, correct, or supply what is actually used, how each item is used, what changed, what is missed or refused, what problems or barriers exist, and who assists. Ask explicitly about OTC products, supplements, natural treatments, samples, inhalers, injections, eye or ear products, creams, patches, liquids, and PRN items. L1 pursues disconnected records or helps with the administrative intake. L2 conducts the human relationship-based interview only when the required service or person request calls for it, or accessibility, ambiguity, conflict, distress, disagreement, or relationship context remains.
3. Confirm allergies and previous reactions. Collect the separate allergy/reaction history and preserve disagreements for clinical review.
4. Collect independent sources. Obtain available EHR lists and orders, prior reconciliation, PCP and specialist records, pharmacy and claims events, bottles or photographs, facility MAR or administration records, discharge instructions, home health records, and beneficiary/caregiver reports. Record what is still missing.
5. Normalize identity conservatively. L0 may perform exact approved terminology mapping. Strength, concentration, form, route, release characteristics, salt, compound, combination product, and ambiguous text remain distinct unless the evidence supports the match. Therapeutic equivalence is never an automated identity decision.
6. Compare medication by medication. Identify exact matches and differences involving omission, addition, ingredient, strength, concentration, form, route, dose, frequency, timing, PRN instructions, hold or stop instructions, intended overlap, substitution, indication, prescriber, supply, administration, and reported use. Distinguish documented intentional differences from unexplained differences.
7. Prepare the clinician packet. Present the best available history, every source assertion, allergy/reaction record, literal discrepancies, reported symptoms and actual use, access and administration barriers, transition context, relevant existing clinical information, pending questions, and original source documents. AI may summarize but cannot remove contradictions or declare the list clean.
8. Perform prescribing-authority reconciliation. The clinician evaluates the complete packet and determines, for every medication or substance, whether the intended regimen is to continue, start, stop, hold, change, or use under specified conditions. The clinician records dose, route, frequency, indication or purpose, effective timing, clinically important conditions, rationale for material differences, and required monitoring.
9. Record separate clinical and real-world facts. The clinician separately records the intended regimen, beneficiary-reported use, apparent supply or possession, administration evidence, and remaining uncertainty. The clinical conclusion does not erase contradictory evidence.
10. Classify the reconciliation result. The clinician records complete without changes, complete with changes, or incomplete because material information remains unavailable or disputed. A no-change conclusion requires disposition of every material discrepancy. For an incomplete result, the clinician identifies the current instruction that remains in effect or states that no safe new instruction can be released, lists unresolved questions, assigns follow-up, and defines safeguards.
11. Route every proposed change correctly. Distinguish a GUIDE-originated proposal, an authenticated outside order already issued or effective, an outside recommendation without an order, and a beneficiary self-change. Apply the procedures below.
12. Issue and execute authorized orders. After the required clinical authority and provider agreement are authenticated, the authorized prescriber may create the lawful order or cancellation under clinical policy. Before a non-emergency change is implemented or communicated as active instructions, explain it and record the beneficiary's or authorized representative's choice. Track the recommendation, agreement, order, transmission, pharmacy response, dispensing or handoff, possession, choice, and reported implementation separately.
13. Synchronize required destinations. Update the EHR medication record, care plan, pharmacy, beneficiary instructions, authorized caregiver or representative, facility administration information, schedule support, and applicable clinicians as required. One successful destination does not prove another.
14. Communicate and confirm understanding. Provide accessible clinician-approved instructions and use teach-back. Do not represent a proposal as an active regimen.
15. Implement practical supports. After the regimen is clinically authorized and understood, L2 helps address access, packaging, reminders, pill organizers, applications, caregiver/facility support, and other chosen aids without simplifying conditional clinical directions.
16. Monitor and follow through. Confirm whether the beneficiary obtained and reportedly implemented or refused the regimen, whether symptoms or barriers appeared, whether monitoring occurred, and whether every result reached the responsible clinician. New material information creates new review work rather than silently changing the prior record.

Task-level medical operating cards — M01-M16#

These cards make the review-and-reconciliation episode executable. Minute ranges are operating estimates, not CMS minimums, clinical deadlines, or reasons to create work. Count one human episode once even when it satisfies several cards. In particular, M03-M06 share one reported-use intake episode, M07-M09 may share one source-pursuit episode, and M14-M15 share one prescribing-clinician reconciliation episode. Clean software preparation creates 0 human minutes. The ranges below describe low / ordinary / complex cases and must be replaced by observed operating data.

M01. Identify when medication review is due#

When. Evaluate every initial Assessment, future Assessment, authenticated care-team/beneficiary/caregiver request, transition, outside medication event, discrepancy, self-change/refusal, symptom/safety report, or returned monitoring result. A new month, an empty billing month, background surveillance, or no source delta is not by itself a reconciliation occasion.

Required facts and provenance. Event type and source; event/receipt time; current Assessment or transition identity; exact requester and request; medication issue as stated; duplicate/prior review link; and any immediate-safety cue. A claim, alert, or model difference is a candidate event only.

Procedure. Software matches the event to an approved occasion, deduplicates it against open medication work, and records one of: full §7.1 review due; bounded medication question due; transition review due; safety route first; administrative verification needed; no qualifying review occasion; or unresolved occasion under O-028. Independent urgent work proceeds without waiting for occasion classification.

Automation and human work. Software performs the clean determination. L1 verifies an external request, transition, or duplicate fact only when disconnected. L2 enters only when the person's intended request or relationship context is unclear. The prescribing clinician does not review a clean no-trigger event.

Estimated human minutes. Clean: 0. L1 exception: 3 / 7 / 12. L2 relationship clarification: 0 / 5 / 10. Clinical: 0 here; later M14 time applies only when a supported occasion requires reconciliation.

Completion evidence. Exact occasion and scope, source, duplicate disposition, safety precedence, receiving task, and why no review was opened when applicable. Detection, alerting, or task creation alone is not a medication review.

M02. Confirm beneficiary, setting, participants, and clinical authority#

When. Before collecting or disclosing person-specific medication information and again before any licensed act when the beneficiary's location, setting, participant, or clinician authority changed.

Required facts and provenance. Beneficiary match; current physical location and care setting; transition status; respondent identity; beneficiary participation; caregiver/representative basis for this interaction; permitted disclosure scope; preferred language and accommodations; proposed clinician identity, organization, license, jurisdiction, and requested act.

Procedure. Software validates supported identity, participation, location, and roster facts. L1 corrects a missing identifier, current location, endpoint, or credential record. L2 clarifies a beneficiary/caregiver participation or communication issue. If the exact clinical performer lacks beneficiary-location authority, hold only the licensed act and select the appropriate authorized route; do not delay an emergency connection.

Automation and human work. Clean validation is software. No privacy reviewer or clinician blesses a fully supported routine case. A genuine uncovered authority question remains held under the approved legal/clinical escalation rather than being guessed.

Estimated human minutes. Clean: 0. L1 factual correction: 2 / 5 / 10. L2 participation/accessibility clarification: 0 / 5 / 12. Clinical: 0 unless a separate clinical act begins.

Completion evidence. Matched person, location/as-of time, setting, participants, permission scope, accommodations, and exact authorized clinician for the act. A chart header, caregiver label, clinician title, or roster presence alone is insufficient.

M03. Obtain the prescription-medication report#

When. During the source-faithful intake for an applicable M01 occasion. Do not repeat an already current attributable answer unless a new event, correction, conflict, or clinically required question makes it necessary.

Required facts and provenance. Source-separated candidate prescription list; beneficiary/caregiver reporter; current use as reported; unknown products; products not on the candidate list; label/photo/source identifiers; and accessibility needs.

Procedure. Present each candidate as a source assertion, ask what prescription medications are actually used, add omitted items, and record uncertain or declined answers without converting them to no use. Preserve intended order, possession, reported use, and administration as separate facts.

Automation and human work. Accessible software intake is the clean path. L1 assists with an administrative intake or photo/record transfer. L2 conducts a relationship-based interview only when required/requested or when accessibility, ambiguity, conflict, distress, disagreement, or relationship context remains.

Estimated human minutes. Count M03-M06 once as one intake: software-only 0 Proxi human minutes; L1 assisted intake 5 / 12 / 25; L2 human interview 8 / 18 / 35. Do not add those bands separately for each card.

Completion evidence. Reporter, time, each reported prescription item or explicit uncertainty/decline, source links, corrections, and unasked/unresolved items. A copied EHR list or claim history is not the person's current-use report.

M04. Obtain OTC, supplement, natural-treatment, and other-substance reports#

When. In the same applicable intake as M03 and whenever a new product or correction is reported.

Required facts and provenance. Verbatim product/ingredient when supported; label/photo; strength/form/route; reported purpose and use; source/reporter/time; and uncertainty. Ask explicitly about vitamins, supplements, herbs, natural products, samples, inhalers, injections, eye/ear products, creams, patches, liquids, PRN products, and other substances.

Procedure. Use a complete accessible prompt set without presuming the product is harmless or clinically meaningful. Record "none reported" only when the relevant question was actually asked and answered. Route unknown identity, interaction, symptom, or safety questions without interpreting them.

Automation and human work. Same shared M03-M06 intake. Software captures and separates facts; L1/L2 enter only under the shared exception. Product or clinical significance is not decided by intake staff.

Estimated human minutes. Included in the single M03-M06 intake band; typical component 2-5 minutes, not additional billed labor.

Completion evidence. Complete prompt coverage, attributable response, each product assertion, unknowns, declines, and any exact clinical question. A blank field or absence from claims/EHR is not "none."

M05. Record how each item is actually used#

When. For every reported item in the applicable intake and after a new use, nonuse, refusal, self-change, administration, or possession fact appears.

Required facts and provenance. Reported amount, route, timing, frequency, PRN conditions, missed/extra doses, recent start/stop/change, refusal, last known dose when relevant, who organizes/assists/administers, and reporter/time. Keep order, supply, possession, reported use, and administration distinct.

Procedure. Ask source-faithful questions and retain the person's words. Do not label the report adherence/nonadherence, safe/unsafe, correct/incorrect, or authorized/unauthorized. A self-change or possible safety issue invokes the exact protected route while the literal report remains intact.

Automation and human work. Same shared M03-M06 intake. Software structures complex schedules without flattening tapers, alternating doses, multi-strength use, PRN limits, or conditional holds. L2 may clarify practical execution only; the clinician judges clinical meaning.

Estimated human minutes. Included in the single M03-M06 band; typical component 3-8 minutes, varying with medication count and schedule complexity.

Completion evidence. One attributable real-world-use assertion per applicable item, explicit unknowns/conflicts, support person/workflow, and every triggered clinical question. A fill, bottle, pillbox, or MAR field does not prove the person's reported use.

M06. Obtain problems, symptoms, barriers, allergies, and prior-reaction reports#

When. During the same applicable intake and whenever a person reports a medication concern, fall, confusion, sedation, swallowing/device problem, access/administration barrier, allergy, intolerance, or prior reaction.

Required facts and provenance. Exact reporter words; product/substance; event or reaction; timing/onset and severity as reported; actions already taken; access or administration barrier; existing allergy/reaction records and conflicts; callback and current location when a safety route may apply.

Procedure. Capture without confirming, dismissing, grading, or assigning causality. Immediate-danger or urgent-advice content uses the universal safety bypass. Other clinical questions route directly to the exact beneficiary-location-authorized RN, behavioral clinician, prescribing clinician, pharmacist, or outside endpoint required for the act. No RN is a universal gateway.

Automation and human work. Software presents approved prompts, retrieves prior records, highlights literal conflicts, and initiates configured connection steps. The first human receives and connects; only the authorized clinician or outside responder supplies the protected judgment.

Estimated human minutes. Routine capture is included in the M03-M06 band. Safety intake/connection by L1 or L2: 3 / 7 / 12. Authorized clinical response: 5 / 15 / 30+, event-driven and counted once in the protected service, not again here.

Completion evidence. Source-faithful report, location/callback when needed, exact route, live acceptance or active failed-handoff recovery, and attributable clinical/outside disposition. A risk score, alert, message send, or handoff attempt is not a clinical result.

M07. Retrieve clinical medication sources#

When. After a supported review occasion and whenever a material clinical source is missing, stale, corrected, or disputed.

Required facts and provenance. EHR medication lists and orders; stop/cancel orders; allergy/reaction records; prior reconciliation; PCP/specialist/facility/home-health records; author, encounter, effective date, receipt date, system, document/version, and supersession/correction links.

Procedure. Retrieve every connected source, preserve the original, and record unavailable or restricted sources. Software deduplicates copies with the same origin but never discards provenance. L1 requests only the exact disconnected record and matches the returned document to the beneficiary and review.

Automation and human work. Connected retrieval and organization are software. L1 performs one shared manual source-pursuit episode when needed. Clinical staff enter only if source meaning requires judgment, not to chase records.

Estimated human minutes. Clean: 0. L1 manual pursuit: 5 / 12 / 25 shared across M07-M09 where possible. L2: 0. Clinical source clarification: event-driven in M14 or the outside-provider route.

Completion evidence. Source manifest, retrieved originals, provenance/as-of dates, unavailable-source list, requests and results, and matched corrections. A generic "records reviewed" note or copied list is insufficient.

M08. Retrieve pharmacy, dispense, and supply sources#

When. For an applicable review when pharmacy or supply evidence exists or when fill, cancellation, shortage, delivery, pickup, access, or possession is relevant.

Required facts and provenance. Pharmacy/supplier identity; prescription/order reference; dispense, partial fill, reversal, transfer, cancellation, backorder, delivery/pickup, quantity/days supply, claim event, source time, and authenticated pharmacy response.

Procedure. Retrieve connected events, distinguish claim from dispense and dispense from possession, and prepare exact factual questions. L1 contacts the verified endpoint only for missing administrative facts. Clinical clarification, substitution, interaction, or treatment questions route to the pharmacist/prescriber within authority.

Automation and human work. Software is the clean path; L1 handles a disconnected fact; the pharmacy/outside professional supplies source-native facts. No navigator or software infers possession or use.

Estimated human minutes. Clean: 0. L1 manual pharmacy pursuit: 5 / 10 / 20, shared with the M07-M09 pursuit episode when applicable. L2: 0. Protected pharmacist/prescriber time is event-driven.

Completion evidence. Source-specific pharmacy/supply events and unknowns, endpoint/authentication, and separately retained order, claim, dispense/handoff, possession, and reported-use states.

M09. Gather transition medication sources#

When. For every transition between residence and a care setting that creates medication work, including late discharge records, rapid readmission, or corrected transition information.

Required facts and provenance. Pre-transition regimen and reported use; facility/emergency administration; discharge/transfer orders and instructions; transmitted prescriptions/cancellations; pharmacy/supply events; household/facility possession; current reported use; pending tests/results; current location and transition dates.

Procedure. Assemble all settings side by side; never select the discharge list merely because it is newest. Record missing documents and conflicts. The packet routes directly to the exact transition actor still governed by O-028; prescribing authority is mandatory whenever the act determines the intended regimen or performs §7.1 reconciliation.

Automation and human work. Software retrieves and aligns sources. L1 pursues disconnected documents. L2 obtains current practical use/context only for the shared human exception. Care Coordination owns the transition episode; Medication owns only its attributable reconciliation/decision/result.

Estimated human minutes. Clean connected assembly: 0. L1 pursuit: 8 / 20 / 40. L2 exception interview: 0 / 10 / 20. Clinical time is counted in M14, not here.

Completion evidence. Setting-separated source packet, missing-source list, current location/use report, exact receiving clinical authority, and link back to the Care Coordination transition. A discharge list alone is not reconciliation.

M10. Match exact medication products and preserve ambiguity#

When. After source collection and whenever names/codes may refer to the same or different product.

Required facts and provenance. Verbatim names/codes; ingredient; strength/concentration; form; route; release characteristic; salt; combination/compound details; label/photo; source and time.

Procedure. Software performs only approved exact terminology mapping. Record exact match, supported candidate match, or unresolved identity. Do not merge different strength, form, route, release, salt, compound, or combination product unless the evidence supports it. Therapeutic equivalence is protected clinical/pharmacy judgment.

Automation and human work. Clean exact matches are software. L1 obtains a missing label or formulation fact. The exact pharmacist or prescribing clinician resolves protected ambiguity when permitted under O-028; otherwise retain the item unresolved for M14.

Estimated human minutes. Exact path: 0. L1 fact pursuit: 3 / 8 / 15. Pharmacist/prescribing-clinician ambiguity review: 5 / 10 / 20, event-driven and not duplicated in M14 when the same clinician resolves it there.

Completion evidence. Identity map with exact/candidate/unresolved status, reason, and provenance. Model similarity, shared ingredient class, or similar name is not an exact match.

M11. Compare every source assertion medication by medication#

When. After sufficient sources are assembled for an applicable review, and again only when a new or corrected source materially changes the comparison.

Required facts and provenance. Every source assertion for identity, order, intended use, supply, possession, reported use, administration, allergy/reaction, symptom, access, and transition context; documented intentional-difference evidence; and source/as-of time.

Procedure. Software creates a literal difference set for omissions, additions, ingredient, strength, form, route, dose, schedule, PRN/hold/stop directions, overlap, substitution, indication, prescriber, supply, administration, and reported use. Mark a difference documented-intentional only when an attributable source says so; otherwise retain unexplained. Do not decide clinical significance or that no difference means no review.

Automation and human work. Exact comparison is software. L1 clarifies administrative facts; L2 clarifies an actual-use or practical report only under the shared exception. The prescribing clinician interprets every material difference during M14.

Estimated human minutes. Clean: 0. Shared L1 clarification: 0 / 5 / 15. Shared L2 clarification: 0 / 5 / 12. No clinical minutes until M14 unless a separate safety event occurs.

Completion evidence. Source-by-source assertion ledger, literal difference set, documented/unexplained basis, and unresolved facts. No source delta, newest-list selection, or AI "clean list" is not reconciliation.

M12. Pursue only the missing material facts#

When. When M07-M11 identifies a missing fact that matters to the applicable review, safety, identity, intended-regimen decision, or required explanation.

Required facts and provenance. Exact missing fact; why it is material; likely source/endpoint; permitted request content; due/return condition; current safe instruction or safeguard where already supplied by a clinician.

Procedure. Request the smallest factual unit from the beneficiary, caregiver, prescriber, pharmacy, facility, or record source. Track delivery, matched response, exact returned fact, refusal/unavailability, and whether the new fact changes the packet. Do not ask L2 to repeat routine source pursuit or ask the clinician to gather data that can be prepared first.

Automation and human work. Software sends and tracks approved requests. L1 performs disconnected administrative pursuit. L2 enters for beneficiary/caregiver ambiguity, distress, disagreement, or a relationship-sensitive question. The clinical owner defines whether a fact is dispensable or the result remains incomplete.

Estimated human minutes. Clean electronic return: 0. L1 pursuit: 5 / 13 / 30. L2 relationship clarification: 0 / 7 / 15. Clinical decision about unresolved materiality is included in M14.

Completion evidence. Request, endpoint, permission, matched response, source-native fact or truthful non-success, packet update, and remaining unresolved material facts. Attempted outreach or a generic response is not completion.

M13. Prepare the clinician reconciliation packet#

When. After M01-M12 establish a supported occasion and the best available source set, or earlier when an urgent clinical route needs a focused packet.

Required facts and provenance. Occasion/scope; identity/location/authority; source manifest; reported-use history; allergy/reaction history; source assertion ledger; exact matches and unresolved identities; literal discrepancies; symptoms and barriers; transition context; missing material facts; current known instructions; original source links.

Procedure. Software builds a concise priority view plus full expandable evidence. It must preserve every contradiction and unknown, distinguish source facts from summaries, and name the exact question requiring judgment. Readiness outcomes are: ready for M14; missing facts visibly retained for a possible clinician-authored incomplete result; further factual pursuit requested without blocking unaffected medication work; urgent focused route; wrong/unauthorized clinician; or source-sufficiency rule gap held under O-028. Missing medication facts do not automatically prevent the clinician from stating that reconciliation is incomplete, the current instruction that remains applicable, or that no safe new instruction can be released.

Automation and human work. Clean assembly and readiness checks are software. L1 corrects a factual source/link error; L2 corrects only that person's own report/context. The clinician reviews, but does not rebuild, the packet.

Estimated human minutes. Clean: 0. L1 correction: 0 / 3 / 8. L2 correction: 0 / 3 / 8. Clinician orientation time is counted in M14.

Completion evidence. Source-linked packet, exact review question, preserved conflicts/unknowns, readiness or held reason, and routed authorized clinician. A summary, risk score, or assigned task alone is not ready-for-reconciliation proof.

M14. Perform prescribing-authority reconciliation#

When. When a supported §7.1 or otherwise approved reconciliation occasion exists, the best available packet is ready, the beneficiary's current location is known, and the performing clinician has prescribing authority for the act. Immediate safety work may precede or run beside reconciliation.

Required facts and provenance. Full M13 packet; current clinical goals and relevant clinical data; discrepancies and missing facts; beneficiary preference; exact prescriber/treatment ownership; monitoring needs; and the clinician's identity, credential, organization, location authority, and scope.

Procedure. The clinician reviews the packet and, for each medication/substance, determines continue, start, stop, hold, change, or conditional use; records exact dose/route/frequency/purpose/effective timing; dispositions every material discrepancy; preserves separate reported use, supply/possession, and administration facts; identifies rationale and monitoring; and states what remains unknown. The clinician executes judgment—this is not a blessing of an AI/L1/L2 draft.

Automation and human work. Software navigates evidence, displays comparisons, and records the clinician-authored determinations. L1/L2 are absent from clean clinical review unless the clinician requests a missing factual or participant clarification. Only the exact beneficiary-location-authorized prescribing clinician performs reconciliation.

Estimated human minutes, with minute-by-minute composition. Low case 12 minutes: orient to packet 3, review/disposition 7, author result/monitoring 2. Ordinary case 25 minutes: orient 4, resolve discrepancies and regimen 15, author result/monitoring 6. Complex case 45 minutes: orient 5, multi-source/multi-clinician judgment 30, author result/safeguards/monitoring 10. Additional treatment work outside reconciliation is separate.

Completion evidence. Clinician-authored intended regimen, medication-level dispositions, every material discrepancy resolved or explicitly retained, rationale, monitoring, separate real-world facts, identity/authority, date/time, and M15 result. Time spent or electronic sign-off alone is not reconciliation.

M15. Record the truthful reconciliation result#

When. Immediately after M14 and again only when the clinician authors a corrected or superseding result.

Required facts and provenance. M14 medication-level dispositions; material-discrepancy inventory; unresolved sources/questions; current instruction; ability or inability to release a new instruction; safeguards; owners; monitoring and follow-up.

Procedure. The clinician-authored result is exactly one of: complete without change; complete with change; or incomplete. No-change requires every material discrepancy disposition. Incomplete must state the current instruction that remains in effect or that no safe new instruction can be released, plus unresolved questions, safeguards, owner, and return condition. Software may draft the classification record but cannot choose it.

Automation and human work. This is part of the same M14 clinical episode. Software validates required fields and routes downstream obligations. L1/L2 may pursue those obligations but do not reclassify the clinical result.

Estimated human minutes. Clinician 1 / 3 / 7 component minutes included inside M14, not a separate review. L1/L2: 0 here; later factual pursuit is counted under M12 or the receiving service.

Completion evidence. Attributable classification, supporting discrepancy dispositions, current instruction/no-safe-new-instruction statement, safeguards, owners, and follow-up. "Reviewed," clinician acknowledgement, comparison complete, or no source delta is not a result.

M16. Explain the result and return it to the person and affected work#

When. After M15 supplies an authorized result, and again when a corrected result or returned answer materially changes what the person must understand. Do not present a proposal or incomplete draft as active instructions.

Required facts and provenance. Clinician-approved explanation; current instruction; what changed/did not change/remains uncertain; effective timing; safeguards and monitoring; permitted recipients and disclosure scope; language/accessibility; beneficiary/caregiver questions; exact affected Assessment, Care Plan, Care Coordination, Ongoing, pharmacy, facility, or outside-provider return.

Procedure. The clinician may explain that clinician's own result directly within authority and answers protected questions. A separate L2 delivery/reinforcement, caregiver or facility disclosure, changed destination, corrected content, or other medication-result release remains held wherever the exact O-030 communication performer and release rule is unresolved. When an approved route applies, L2 may reinforce exact content, address access/scheduling/practical supports, and conduct a bounded understanding check without adding clinical meaning. New clinical questions return to the clinician. Each affected pillar receives the source-linked result and opens only its own necessary work; explanation does not prove order execution, possession, use, or monitoring.

Automation and human work. Software renders accessible approved content, applies already approved recipient/channel rules, records delivery, and tracks questions/returns. It does not infer comprehension or authorize an unresolved release class. L2 enters only under an approved O-030 route for human explanation/support; the clinician enters for clinical meaning or unresolved questions.

Estimated human minutes. L2 approved explanation/support: 3 / 8 / 15. Prescribing clinician explanation: 0 / 7 / 15 for no-change/ordinary questions and 10 / 20 / 30 when change, uncertainty, or complex medical questions require clinical discussion. Shared clinician/L2 interaction minutes are counted once by actual performer.

Completion evidence. Exact content and source; performer; recipient/authority; accessible delivery; questions and answers/routing; person-stated understanding or remaining uncertainty; next action; and each cross-pillar return. Delivery, "do you understand," portal availability, or navigator paraphrase alone is insufficient.

Prescribing-clinician reconciliation checklist#

The prescribing-authority clinician considers, as applicable to the person and medication:

• the indication, current clinical goal, expected benefit, and beneficiary preference;
• exact dose, route, formulation, schedule, duration, PRN conditions, and transition phase;
• therapeutic duplication, intended overlap, interaction, contraindication, and allergy/reaction information;
• age, renal, hepatic, laboratory, vital-sign, diagnostic, or other clinical information required by an approved clinical rule, including whether the information is current and valid;
• symptoms, adverse-effect concerns, falls, cognition, function, behavior, swallowing, device use, and ability to execute the regimen;
• differences between orders, supply, possession, administration, and reported use;
• access, affordability, coverage, shortage, packaging, transportation, caregiver, and facility constraints;
• prescriber and condition ownership, co-management, and the provider whose agreement is required for a GUIDE-originated proposal;
• necessary patient/caregiver education, schedule support, and monitoring; and
• whether each discrepancy is intentional, resolved, still unknown, or requires another professional's action.

A deterministic high-risk, interaction, duplication, dose, or monitoring match creates a clinician-review condition only. It does not create an automatic risk conclusion, recommendation, or medication change. The current CMS DAE performance measure is not an individual deprescribing rule.

GUIDE-originated medication-change procedure#

1. The authorized Participant APN, PA, or physician determines that a medication start, stop, dose, schedule, or other change is clinically advisable and records the exact proposal, rationale, effective timing, and monitoring plan.
2. Identify separately every PCP or specialist to whom the recommendation must be shared and the relevant provider whose agreement is required before the beneficiary changes medication.
3. Prepare the exact proposal for authorized release. Under V1, Proxi may assemble and track it; the human role approved under O-030 releases it.
4. Agreement requires an authenticated response from the relevant provider acting within scope and responding to that exact current proposal. Delivery, elapsed time, silence, office-staff acknowledgment, a response to an old proposal, or partial agreement is not agreement.
5. A modified response creates a new proposal. A declined, missing, stale, wrong-scope, unauthenticated, or revoked response leaves the proposed change inactive while the current regimen remains the operative reference pending authorized disposition.
6. The proposal may be discussed as a proposal, but staff must not present it as active instructions while required agreement remains outstanding.
7. After required provider agreement is authenticated for the exact proposal, the authorized prescriber may issue the lawful prescription or stop order according to clinical policy. Outside-order and emergency pathways remain separate.
8. Before a non-emergency change is implemented or communicated as active instructions, explain the change and record the beneficiary's or decision-specific authorized representative's informed choice. A capable beneficiary's refusal remains separate from the clinical recommendation, lawful order, reported implementation, and caregiver disagreement.
9. Do not release start, stop, hold, or change instructions until the required agreement is complete, a lawful current order exists, and the beneficiary or authorized representative has chosen to proceed, except under an approved emergency pathway.

Outside order, recommendation, and self-change procedure#

• Authenticated external order already issued or effective: preserve it as an outside clinical event, verify source and authority, determine its current applicability, and reconcile it with the current regimen. Do not force it through the GUIDE-originated proposal route merely because GUIDE received it.
• External recommendation without an order: preserve and route it for clinical adoption, rejection, or clarification. It is not active instructions.
• Administrative or ambiguous message: verify the source and exact content; office staff, a fax cover sheet, or an unsigned excerpt cannot create a medication order or agreement.
• Beneficiary self-change or refusal: record actual reported use, reason, symptoms, and decision authority; invoke reconciliation and safety review as applicable. Never treat the action as retrospective authorization.

Order, pharmacy, possession, and implementation procedure#

Confirm separately, as applicable:

1. lawful order or cancellation authored by the authorized prescriber;
2. successful transmission to the verified pharmacy or supplier;
3. pharmacy technical acceptance, rejection, or request for clarification;
4. clinical clarification or substitution decision by the authorized professional;
5. preparation, partial fill, trial fill, emergency supply, transfer, backorder, return-to-stock, or cancellation status;
6. dispensing or handoff to the beneficiary, caregiver, courier, or facility;
7. apparent household or facility possession and accessibility;
8. placement in packaging, pill organizer, reminder, MAR, or administration workflow;
9. beneficiary or caregiver report of starting, stopping, changing, delaying, or refusing; and
10. actual administration evidence when available.

For a stopped or cancelled medication, determine whether previously supplied medication remains possessed, accessible, placed in a pill organizer, administered by a facility, or reportedly taken. L2 may gather facts and provide only approved practical support; disposal, replacement, or clinical instructions require the appropriate authorized source.

Accessible instruction and teach-back procedure#

The clinician-approved instruction must distinguish what continues, starts, stops, changes, remains on hold, or remains uncertain and must include, as applicable, dose, route, timing, PRN or conditional directions, effective date, purpose, monitoring, approved missed-dose instruction, and what to do if a problem occurs.

L2 or another approved care-team member asks the beneficiary or authorized caregiver to explain in their own words:

• which medications continue, start, stop, change, or remain on hold;
• how much, how, and when each applicable item is used;
• any PRN condition, maximum, taper, alternating schedule, or conditional hold;
• which existing supply or packaging is affected;
• what monitoring or follow-up is expected;
• what warning signs and contact actions the clinician approved; and
• who will help and how the schedule support works.

Correct misunderstandings and repeat teach-back. Asking “Do you understand?” is not evidence of comprehension. If understanding cannot be demonstrated, do not document comprehension or automatically infer incapacity. With the beneficiary, identify an authorized support person or another practical aid and return unresolved safety, capacity, swallowing, device, or administration concerns to the appropriate clinician.

Schedule supports are built only from the current authorized regimen. A taper, cross-titration, alternating schedule, PRN maximum, multiple strength, or conditional hold must not be flattened into a static reminder.

Monitoring procedure#

For every medication or change requiring follow-up, the prescribing clinician defines:

• what will be monitored, including symptoms, function, falls, behavior, actual use, access, vital signs, laboratory results, other testing, or a clinical visit as applicable;
• who obtains each input and by what permitted route;
• who is clinically responsible for reviewing the result;
• clinically appropriate timing and what finding requires earlier contact;
• what action or communication is expected after review; and
• how missed, unavailable, stale, conflicting, or late monitoring is escalated.

L0/L1 may remind, retrieve, and track. L2 may support completion and report observations. Only the authorized clinician interprets the result and decides medication action. A reminder sent or test completed does not prove clinical review.

Transition-specific medication procedure#

For transitions, compare all applicable source classes rather than selecting the discharge list by recency:

1. regimen and reported use before the transition;
2. medication actually administered in the facility or emergency setting;
3. discharge or transfer orders and instructions;
4. prescriptions and cancellations actually transmitted;
5. pharmacy responses and supply events;
6. medication physically present at home or the receiving facility;
7. what the beneficiary, caregiver, or facility is currently doing; and
8. pending tests, results, monitoring, and responsibility for follow-up.

The completed transition medication outcome must return to the Care Coordination transition episode. Missing discharge information, a newly issued outside order, rapid readmission, or late corrected record remains visible and creates the applicable follow-up; it does not silently overwrite the reconciled regimen.

Timing and escalation#

Objective completion criteria#

A prescribing-authority medication review or reconciliation is complete only when the record contains:

• the trigger and scope of the review;
• beneficiary identity, current location, respondent and authority facts, and accessibility needs;
• the source-complete medication and allergy/reaction history or an explicit list of unavailable sources;
• every material discrepancy and its prescribing-clinician disposition;
• clinician identity, credentials, beneficiary-location authority, date, and the exact intended regimen;
• separate reported use, supply/possession, administration, and unresolved facts;
• complete-without-change, complete-with-change, or incomplete outcome, with no-change supported by disposition of every material discrepancy;
• for a GUIDE-originated change, the exact sharing recipients, relevant agreement provider, authenticated response to the current proposal, beneficiary decision, and lawful order;
• required EHR, care-plan, pharmacy, beneficiary, caregiver/facility, schedule-support, and other-clinician communication outcomes;
• accessible instruction and teach-back result without unsupported comprehension;
• access, pharmacy, possession, implementation, refusal, and monitoring outcomes as applicable; and
• every unresolved issue, safeguard, responsible owner, timing, and next action.

An alert, completed source comparison, clinician task assignment, transmitted proposal, pharmacy claim, safety handoff, or narrative note alone is not medication-service completion. Case completion and whether an activity qualifies as a GUIDE service remain separate under O-034.

Cross-pillar medication feeds#

This SOP participates in cross-pillar episodes under 25_GUIDE_Eight_Pillar_Service_Integration.md. Medication Management receives service attribution only for an attributable prescribing-authority reconciliation or decision, a truthful incomplete result, an executed medication access or change step, or an authorized monitoring result with the next owner identified. Opening a medication case, ingesting a list, sending a transfer, issuing an order, or obtaining pharmacy acceptance does not silently stand in for the later result.

Assessment opens the required reconciliation occasion and supplies source material. Ongoing Monitoring asks only the bounded current-use or problem question unless a real trigger exists, then follows the exact access, use, or monitoring return without performing reconciliation. During a transition, the medication work remains incomplete until the route-specific authorized clinician produces a complete-no-change, complete-with-change, or truthful incomplete result and any safe current instruction or inability to release a new instruction is explicit under the still-open O-028 authority decision.

What this pillar provides as a service#

Proxi can perform or accelerate intake, retrieval, comparison, task creation, follow-up, communication preparation, status tracking, reminders, and record updates. The required human service remains the beneficiary or caregiver interaction, prescribing-authority reconciliation and judgment, relevant-provider agreement, lawful prescribing or deprescribing, clinical safety response, and care-navigator support.