NYGH Paper Med Rec - Safer Healthcare Now!

Medication Reconciliation
Form
Patient Identification
PLEASE COMPLETE WITHIN 24 HOURS OF PATIENT ADMISSION
DATE OF ADMISSION (YY/MM/DD):
MEDICATION ALLERGIES/INTOLERANCES:
SOURCE OF MEDICATION INFORMATION (indicate choice with a check mark)
NO MEDICATIONS ON ADMISSION ___________ Initial/Date Review of medication bottle
Medication Administration Record from another facility
Patient medication list
Patient/family recall
Other (specify):
Pharmacy [Name: Tel: ]
MEDICATION HISTORY LIST
Medications on Admission
Physician Reconciliation
Medication Name/Strength Dose Route Freq 1 Duration 2 Last Dose
Date/Time
Staff
Initials
& time
Continue
(MD
Initials)
Change
(MD
Initials)
Hold or
D/C 3
(MD
Initials)
1 Freq indicates frequency.
2 Duration indicates how long the patient has been taking the medication.
3 D/C indicates discontinue.
Signature/Designation Initials Signature/Designation Initials Signature/Designation Initials
If Pharmacist consultation is required, please specify on physician orders.
THIS IS NOT AN ORDER FORM
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Instructions for Reconciling Medications
Medication Reconciliation is a process designed to prevent medication errors at patient
transition points. It includes:
1. Creating the most complete and accurate list of all home medications for each patient.
2. Using that list when writing medication orders.
3. Comparing the list against the physician’s admission, transfer and/or discharge
orders; identifying and bringing any discrepancies to the attention of the physician
and, if applicable, making changes to the orders ensuring the changes are
documented.
Source: www.saferhealthcarenow.ca
PROCEDURE
1. The Medication Reconciliation Form will be located in front of the physician orders on each
patient’s chart.
2. Nurses, Physicians and Pharmacists are responsible for completing the reconciliation form
within 24 hours of the patient’s admission if possible. A complete form will include patient
identification; date of admission; medication allergies/intolerances; source of medication
information; drug name, dose, frequency, route, duration and the date/time of last dose.
Medication information can be added to the “Medications on Admission” section of the form
by any clinician as they are determined. If the patient does not have any medications on
admission, the clinician will check NO MEDICATIONS ON ADMISSION in the source of
medication information section on the form.
a. Medications that the patient was taking prior to admission will be documented in
the “Medications on Admission” section of the form by the Hospitalist, Nurse and
Pharmacist when the patient is assessed on the unit.
b. If the medication list already contains documentation by another clinician, the
Staff or Hospitalist will confirm the documented medications with the
patient/family and document any additional preadmission medications.
c. If medication information already written on the form is incomplete or inaccurate,
the clinician will change or correct the information, and initial and date their
changes. Staff will place their initials in the “Staff Initials” column only when the
entire line is complete.
d. The Hospitalist will complete the shaded “Physician Reconciliation” section of
the form. The “Physician Reconciliation” section can only be completed by
physicians. The Hospitalist will place their initials in the appropriate box
depending on whether they wish to CONTINUE, CHANGE OR,
HOLD/DISCONTINUE the medication.
e. If additional medications have been added, the Hospitalist must be contacted to
complete the “Physician Reconciliation” section of the form.
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