Medication Reconciliation Audit Tool Template
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2MEDICATION RECONCILIATION AUDIT TOOL
Facility: _____________________________________________Date:_______________________________
Data Collector’s name: _________________________________Email/Phone:________________________
Purpose: To evaluate your facility’s internal medication reconciliation processes: 1) the collection and accuracy of the
home medication list, 2) the accuracy and timeliness of the medication reconciliation of the home list to the admission
orders, 3) the documentation of rationale for intended medication discrepancies, and 4) the incidence of unintended
medication discrepancies.
Instructions:
Using the criteria below, audit 5-10 medical records of patients discharged from your facility on any anticoagulant
(see list below) who have been re-hospitalized within the past 30 days (if there are no re-hospitalizations within 30
days, try 45 days or 60 days, if needed).
Answer Y, N, or UTD (Unable to Determine) to the following audit criteria questions using data elements found in
the patient’s medical record.
For questions contact: Vicky Agramonte, or Anne Myrka,
Please use additional copies of this form if your audit exceeds 5 patient records.
Please FAX this completed form to 518-426-3418 to Vicky or Anne (main phone:518-426-3300)
Medication Reconciliation Audit Criteria
Pt. 1
Pt. 2
Pt. 3
Pt. 4
Pt. 5
Y/N/UTD
Y/N/UTD
Y/N/UTD
Y/N/UTD
Y/N/UTD
Was an original home medications list collected on
admission?
Did the list of original home medications collected at
admission include the medication name, dose, route
and frequency for each medication? (all elements
for all drugs must be present for Yes)
Was the original home medication list reconciled
with admission orders in less than 24 hours?
Did the reconciled medication list reside in a
dedicated location in the medical record?
Was there is a 1:1 match for every medication on
the home medication list to the admitting orders?
(all elements for all drugs must match for Yes)
For medications without a 1:1 match, was a
rationale for the discrepancy documented? If No,
please complete the Medication Discrepancy Tool
(MDT- see below) (use one MDT for each applicable
patient record).
Total “No” and “UTD” Responses
“Original Home medications list” refer to medications the patient was taking where they lived prior to admission to your facility
and includes lists provided by skilled nursing facilities, assisted living facilities, adult homes, home healthcare agencies, etc.
Anticoagulants: Coumadin (warfarin), Pradaxa (dabigatran), Xarelto (rivaroxaban), Eliquis (apixaban), Lovenox
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(enoxaparin), Arixtra (fondaparinux), Heparin, Fragmin (dalteparin), Innohep (tinzaparin)
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