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/drug-
interactionchecker
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/drug-
interactionchecker Note any potential reactions

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 STUDENT NAME:
PREADMISSION MEDICATION LIST
VERIFICATION AND ORDER FORM PATIENT NAME:

(Medication Reconciliation) 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 CIRCLE C to continue OR
Medication Administration Record from facility DC to discontinue
Other: _______________________________
Drug Dose
MEDICATION HISTORY RECORDED/VERIFIED BY: _____________________ PHYSICIAN
clarification clarificatio
ORDER
required n required
ROUTE Continued Hold until Hold until
MEDICATION NAME DOSE LAST DOSE
(PO, GT, FREQUENCY on clarified with clarified with
(WRITE LEGIBLY) (mg, mcg, ) DATE/TIME
SC, IV) Admission MD 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:

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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