2

0
0
7

M
E
D
-
P
A
S
S
,

I
N
C
.
F
o
r
m

#

M
P
5
2
1
5






0
5
/
0
7
I
N
H

0
3
1
4
0
7
R
e
o
r
d
e
r

F
r
o
m
:































8
0
0
-
4
3
8
-
8
8
8
4
MEDICATION RECONCILIATION FORM
Quality Assurance Admit / Readmit
Resident/Patient Name: Date of Birth:
Allergies:
M
O
D
I
F
Y
O
R
D
E
R
D
A
T
E

A
N
D
T
I
M
E


O
F
L
A
S
T

D
O
S
E
(
I
F

A
V
A
I
L
A
B
L
E
)
A
D
M
I
T
T
I
N
G
O
R
D
E
R
S
D
C
S
U
M
M
A
R
Y
P
R
E
V
I
O
U
S
M
A
R
M
E
D
I
C
A
T
I
O
N
D
O
S
E
F
R
E
Q
U
E
N
C
Y
R
O
U
T
E
C
O
N
T
I
N
U
E
O
R
D
E
R
D
I
S
C
O
N
T
I
N
U
E
O
R
D
E
R
Outcome of review
discrepancy (orders written
on physician order sheet)
If No, which
element requires
review?
LIST ALL MEDICATIONS IDENTIFIED
(reported by family, patient, med bottles, include dose,
frequency, route and PRN medications)
If No, seek info from providers in
hospital, community, physician,
family, patient & document diagnosis
or rationale on order sheet
Is there an
indication in
dc summary
to support
med ordered?
D
A
T
A
S
O
U
R
C
E
*
MEDICATION NAME DOSE FREQ. ROUTE Yes No
3 - Documentation from referring facility (e.g. hospital discharge summary, LTCF transfer form, etc.)
4 - Resident/family member statement
5 - Other (specify) ___________________________________________________________
6 - Other (specify) ___________________________________________________________
Do all medication
records match?
Y = Yes N = No
FORM COMPLETED BY: Signature: Title: Date Time:
Facility Name:
Admitted From: Admission Date: Time:
*DATA SOURCE: use one of the following numbers to specify the source of information for each medication
1A - Prescription from _______________________________________________ (Pharmacy) _________________ (Phone)
1B - Prescription from _______________________________________________ (Pharmacy) _________________ (Phone)
2A - Contact with previous primary care physician(s) ____________________________(Name) _________________ (Phone)
2B - Contact with previous primary care physician(s) ____________________________(Name) _________________ (Phone)

IF PRN
INSTRUCTIONS FOR USE: Medication reconciliation is a formal process of obtaining a complete and accurate list of each patients current medications (including
name, dosage, frequency and route) and comparing the incoming admission, transfer, and/or discharge medication orders to that list. Discrepancies are brought to
the attention of the prescriber and, if appropriate, changes are made to the orders. Any resulting changes in orders are documented. Use this form to list all prescription,
non-prescription (OTC), herbal / vitamin medications, patches and inhalers either taken routinely or on an as needed (PRN) basis. File according to facility policy.