Medication Reconciliation Form NUR 240 DISRTICT MEDICATION ASSIGNMENT FALL 2012 Please complete a reconciliation form for each of the assigned clients in the SIM MED district medication assignment before your scheduled nursing lab rotation for dsitrict medications. [Type text] Page 1 INSTRUCTIONS FOR PROPER USE OF MEDICATION RECONCILIATION FORM: Enter student name, patient name and date completed at top of page. Print a separate sheet for each patient. Patient medications from home 1. Enter sources; pt, family 2. Check hyperlink from presentation that indicates client’s response when asked about medications from home 3. Study the list; ask yourself if the medications are appropriate for the client’s medical history or require further inquiry. If you think that a medication may be inappropriate enter information under Drug/Dose Clarification: Patient edmication list” 4. Print medication information onto reconciliation form in space provided 5. Indicated when medication was last taken 6. Compare list to physician orders 7. Circle “c” if continued on admission or “DC” if discontinued 8. Review the client’s reason for taking the medication and compare to the standard of care for a client with that condition, labs results etc (consider the client’s prior medical history) 9. Check for interactions by entering medication profile into http://reference.medscape.com/druginteractionchecker 10. Place a check in the box for “Drug clarification required” if the review of client information; clinical status, labs, condition, prior medical history indicate that you need to talk with the prescribing physician 11. Place a check in the box for “Dose clarification required” if the review of client’s medication dose is inconsistent with standard of care, clinical condition or previously prescribed amount. Explain rationale in section labeled: “clarification/concern: patient medication list” Medications from physician order sheet 1. Add sources; MAR and physican orders 2. Record medications from MAR onto Reconciliation form that have not already been entered. Add additional sheets if necessary. 3. Check physician orders to the standard physician order set at hyperlink to determine if appropriate medications are ordered a. If a medication is missing or dose is different, record “Drug/dose clarification required”. Explain rationale is section labeled “clarification/ concern: Orders” 4. Perform med check from MAR to physician orders and look up medications a. Note any errors, precautions/contraindications that require further clarification. Record “Drug/dose clarification required”. Explain rationale is section labeled “clarification/ concern: MAR” b. You will not be able to administer medications that are not clarified. Pencil hold in space for the administration time until clarified. 5. Check for interactions by entering medication profile into http://reference.medscape.com/druginteractionchecker Note any potential reactions 2 STUDENT NAME: PREADMISSION MEDICATION LIST VERIFICATION AND ORDER FORM (Medication Reconciliation) PATIENT NAME: DATE COMPLETED: Allergies: LIST BELOW ALL OF THE PATIENT’S MEDICATIONS PRIOR TO ADMISSION INCLUDING OTC AND HERBAL MEDS NEW MEDICATIONS OR MEDICATION CHANGES SHOULD BE WRITTEN ON ADMISSION ORDERS Source of Medication list: (check all used) Patient medication list Patient/Family recall Pharmacy _________________ Primary care physician list / PCHIS Physician order list Medication Administration Record from facility Other: _______________________________ MEDICATION HISTORY RECORDED/VERIFIED BY: MEDICATION NAME (WRITE LEGIBLY) DOSE (mg, mcg, ) _____________________ ROUTE (PO, GT, SC, IV) FREQUENCY LAST DOSE DATE/TIME CIRCLE C to continue OR DC to discontinue Drug Dose PHYSICIAN clarification clarificatio ORDER required n required Continued on Admission Hold until clarified with MD Hold until clarified with MD 1. C DC 2. C DC 3. C DC 4. C DC 5. C DC 6. C DC 7. C DC 8. C DC 9. C DC 10. C DC 11. C DC 12. C DC 13. C DC 14. C DC 15. C DC PROHIBITED ABBREVIATIONS: 3 Concerns/Clarification Needed From Patient Medication List Concerns/ Clarification Needed From Comparing The Physician Orders To The Standard Physician Order Set Concerns/Clarification Needed From Medication Administration Record/Potential Interactions 4