Medication Reconciliation Form

What Is A Medication reconciliation Form

There are several points along a patient’s path through the healthcare system where medications can be missed, transcribed incorrectly, or otherwise documented in error. For patients who have had transitions of care, e.g. changing providers, locations, or practitioners, this reconciliation process is particularly important. Having an accurate list of current medications is one of the most integral parts of a patient’s medical history, and when there are discrepancies in what medications the patient is currently taking, or which they should continue with, the risk of making a poor treatment decision greatly increases.

Our is designed to ensure any discrepancies in a patient’s medication regime are resolved, and an accurate and complete list of current medications can be reconciled from the information gathered. This is a two-step process, with the first being gathering the best possible medical history (BPMH) of the patient, including as much information on all medications the patient has been prescribed previously as possible. The second step is resolving any discrepancies identified, for example, if two medications have been prescribed for the same condition, or if two different dosages are documented. For each discrepancy, a decision must be made as to how this discrepancy will be solved. Once all discrepancies are resolved, you can proceed to the final reconciled medication table.

How To Use This Template For Medication Reconciliation Forms

Achieving the best possible medication reconciliation for your patient is a careful and involved process, and while this form is designed to help you work methodically, it is a good idea to understand how exactly to proceed using this form.

Step One: Patient Information

The first thing you have to do is fill in your patient’s information. This section includes information on their allergies, medication management, and their community pharmacy contact details. As conducting a medication reconciliation is a team effort between physicians, nurses, pharmacists, the patient, and their family/caregivers; having these contact details will be very handy.

Step Two: Best Possible Medication History (BPMH)

Now we can begin the information-gathering stage. If you cannot trust the EHR to be comprehensive, i.e. they are a new patient to your hospital, then use whatever resources you have to obtain information on your patient’s medication history, including interviewing your patient and their family, through previous discharge letters or medication orders, requesting pharmacy records, looking at labels on the patient’s medication bottles or boxes, or however else you can obtain this information. As you go, note down the sources you used to obtain this information so someone in the future can trace the sources for this medication reconciliation. As you encounter a new medication, fill it in on the BPMH table, and for any discrepancies, you come across (wrong medication, wrong dosage, incorrect or incomplete prescription etc.) check the discrepancy box.

Step Three: Evaluate Discrepancies in BPMH and Set Actions

Once you’ve obtained the BPMH, it’s time to work through all the discrepancies you found. Within your multidisciplinary team, decide on a resolution plan for each medication. For all medications in the BPMH, conduct a review of the action your patient is to take; “Start” for a new medication to be added to the medication regime, “Continue” for a medication that is to remain unchanged, and “Stop” for any medications the patient is to cease taking.

Step Four: Reconciled Medication List

Take all the medications from the BPMH with actions “Continue” or “Stop” and copy them into the reconciled medication list on the second page of this form. This is your patient’s new medication regime, with all discrepancies resolved and including any new medications.

Step Five: Sign, Date, Store Securely

Ensure for each table that the person completing signs and dates this document to authorize the medication reconciliation form, and to improve accountability within the reconciliation process. If you have worked as part of a team, including the name of the members of your multidisciplinary team here. Lastly, store the reconciliation form securely.

Who Can Use this Printable Medication Reconciliation Form (PDF)?

This medication reconciliation form was designed with all different medical practitioners in mind. The medication reconciliation process is a team process, with input from the patient, their family and caregivers, pharmacists, nurses, and physicians. As such, this form may be used by:

• Nurses and nurse practitioners
• Physicians and resident physicians
• Pharmacists, pharmacy technicians, and trainees
• Midwife practitioners
• Specialty physicians such as psychiatrists.

It is important to note that while the form will be completed by one or more of these professionals working in a team, it is likely that the information gathered will come from all different sources including the patient, their family, and any of their previous medication prescribers.

Why Is This Form Useful For Medical Practitioners

Dedicated Action Section

When working within a team to solve complex problems, it can be easy for loose ends to go untied. To prevent this, we have included a dedicated column for selecting your chosen action. This ensures you have a plan for your patient, and no grey areas remain regarding their medication regime once the reconciliation process is complete.

Highlight discrepancies and resolutions

One of the important decisions you and your team will make as part of the reconciliation process is how to resolve any discrepancies you come across. What will you do if a medication has a dosage that seems incorrect? Or if your patient has been prescribed two medications for the same condition by two different physicians? Your team will rely on your clinical judgment to make these important decisions, and our form can help you highlight the discrepancies you need to address with our discrepancy checkbox column.

Benefits of Client Medication Reconciliation Form Templates

Keep information traceable

By including the names of the medications assessed, the sources used to create the BPMH, and the name and date of the BPMH creation, you help to improve your patient’s medical records for the next time they transfer care.

Flowchart format

A medication reconciliation is more than a single table and involves several steps each requiring your careful attention. To help aid this process, we have created this medication reconciliation form in a flowchart format- where medications identified as to be started or continued in the BPMH flow onto the reconciled medication list.

Improve coordination of care

This tool will prove invaluable for improving the coordination of your patient’s care. With a single, accurate source for your patient’s current medications, all of those involved in your patient’s care will benefit, including pharmacists, nurses, caregivers, or anyone else down the line who treats your patient.

Reduce medication errors

By identifying discrepancies in your patient’s BPMH you stop the error from propagating forward into your reconciled medication list. Within your multidisciplinary team, you can work on a solution to resolve each of these discrepancies, and ensure the reconciled medication list is as error-free as possible.

Standardize the reconciliation process

Medication reconciliations should be conducted for every patient when they are transferring care to a new provider, service, or location. As such, you may have to get very familiar with this process- and so having a standardized method of conducting these reconciliations will be an invaluable tool for you and your team.