Medication Reconciliation List
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1Patient Name: _________________________________________
ECFTA Chart #: _______________
Date: ________________
CCFTA Chart #: _______________
MEDICATION RECONCILIATION LIST
Current medications (please list medications, including dose and how often taken) and over the counter medications
No regular medications
_________________________________time(s) per day
_________________________________time(s) per day
_________________________________time(s) per day
_________________________________time(s) per day
_________________________________time(s) per day
_________________________________time(s) per day
_________________________________time(s) per day
_________________________________time(s) per day
_________________________________time(s) per day
_________________________________time(s) per day
_________________________________time(s) per day
_________________________________time(s) per day
_________________________________time(s) per day
_________________________________time(s) per day
_________________________________time(s) per day
_________________________________time(s) per day
_________________________________time(s) per day
_________________________________time(s) per day
_________________________________time(s) per day
_________________________________time(s) per day
_________________________________time(s) per day
_________________________________as needed
_________________________________time(s) per day
_________________________________as needed
_________________________________time(s) per day
_________________________________as needed
_________________________________time(s) per day
_________________________________as needed
If you go home with your eye patched you will start your drops tomorrow.
Eye Drop Schedule—
Vigamox
one drop
right eye
left eye
3 times a day
4 times a day
Nevanac
one drop
right eye
left eye
3 times a day
4 times a day
Prednisolone Acetate 1%
one drop
right eye
left eye
3 times a day
4 times a day Every 2 hours while awake
Atropine
one drop
right eye
left eye
2 times a day
3 times a day
Erythromycin Ointment ____________ times a day apply to ________________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
Doctor’s Signature: _______________________________ Patient Signature: _______________________________
revised 7/21/10 ccfta form/mediation Reconciliation
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