SASKATOON HEALTH REGION
Saskatoon, Saskatchewan
RUH  SCH  SPH  Other  __________________
PREADMISSION MEDICATION LIST
PHYSICIAN ORDER FORM
Keep this form with the Physician Orders
Allergy / Intolerance to Medication & Food
Weight:
_____ kg, _____lbs
 Estimate,  Actual
(NO MEDICATIONS TO BE ADMINISTERED UNTIL THIS SECTION COMPLETED)
 No Known Allergies
 Unable to obtain (Pharmacy to flag on MAR)
 Allergies as follows:
Height:
____ cm, ____ inches
 Estimate,  Actual
 Check here if
this is an
addendum to or
revision of
previously
completed
medication list.
At Home or Outpatient Prescription, Over the Counter (nonprescription), and Herbal Medications.
List all the patient’s medication taken prior to admission. Herbal medication will not be supplied on admission.
Medication Name, Dose, Frequency,
Route
(list only those medications currently being taken)
Time /
Date of
Last
Dose
Physician Orders
for Individual Medications on Admission
Continue
Stop
Change to (specify):
M
A
R
 continued on page 2
Prescribing Physician: ____________ ; _______________ Date: ______ Time: ___
(print)
(signature)
Obtained history: ____________________________________(signature) __________(title) Date/Time ___________
If PAC visit:
Obtained PAC history: __________________________________(signature) __________(title) Date/Time____________
Reviewed on day of surgery: _____________________________(signature) __________(title) Date/Time ____________
Source of Medication List (check all that apply):
 Patient / Family  MAR from other facility  Medication vials or list  Pharmacy: ___________  Other: ________
Disposition of Patient’s Medication on Admission:
 Locked up in nursing unit  Brought to hospital. Sent home with: ____________________  Not brought to hospital
Physicians - please fully complete additional forms if additional space necessary
Original (white) – Patient’s Chart Copy (canary) – In-patient Pharmacy
Word Form # 102728 05/06 Category: Orders
This form is intended to serve as the pre-admission medication list as well as the physician’s admitting orders
for pre-admission medications. New medication prescribed on admission should be written on the physician’s
order sheet.
Questions to Ask for a Medication History
1. Ask about all medications:
∙ Prescription
∙ Over-the-counter (non-prescription)
∙ Anything from a herbalist or health food store
∙ Vitamins or supplements
∙ Traditional remedies
2. Include:
∙ Name
∙ Dosage form
∙ Dose
∙ Schedule
∙ Last dose taken
Note: be specific about prn medication
3. Ask about recently started medications or dosage
changes
Tips for Performing a Medication History
∙ Balance open-ended questions with yes / no questions
∙ Ask nonbiased questions
∙ Don’t ask leading questions
∙ Vague responses may indicate non-adherence
∙ Avoid medical jargon
∙ Encourage questions from patient
∙ Educate patient to bring medications from home
∙ Educate patient to carry a list of current medications
∙ Prompt regarding non-pill dosage forms such as
patches, creams, eye drops, inhalers, sprays, samples,
shots
∙ Do not assume instructions on prescription vial labels
are current. If the medication vials are available, review
each medication individually with the patient. Ask them
how they take each medication.
∙ Ensure the vial contains the medication specified on the
label.
∙ Prompt regarding prn medication
∙ Allergies: ask about symptoms
∙ Use multiple sources of information:
- Medication labels
- Family
- Community Pharmacy
- Family physician
Other Questions for Medication History Interviews
1.
2.
3.
4.
5.
6.
7.
8.
9.
Did a doctor change the dose or stop any of your medications recently?
Have you changed the dose or stopped any of your medications recently?
Have any of the medications been causing side effects?
Your profile indicates that you may have run out of some medications. Are you still taking any of these?
Have you spent any days in the hospital over the past year?
When you feel better, do you sometimes stop taking your medicine?
Sometimes if you feel worse when you take your medicine, do you stop taking it?
Are the pills in the bottle the same as what is on the label?
Have you changed your daily routine to accommodate your medication schedule?
Physicians - please fully complete additional forms if additional space necessary
Original (white) – Patient’s Chart Copy (canary) – In-patient Pharmacy
Word Form # 102728 05/06 Category: Orders