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]
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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
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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