Form 5-5- 08 - Medicine Reconciliation - 2007
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1
2Date____________
Wt
lbs______kg
Outpatient location:
______
ED
CED
ODS
ENDO
Radiology
Actual
Stated
Other ______________________________________________
Allergies:
Denies
Latex Sensitivity
Meds/Foods/Dyes/Other
Reaction
Meds/Foods/Dyes/Other
Reaction
Information
obtained from:
Patient/Family
Pharmacy
Medicine Bottles
Other: ___________________________
Primary Care Provider: __________________________________________ Office location: _______________________
Pharmacy Name: _______________________________________________ Phone number: _______________________
Outpatient instructions:
HOME MEDICINE/ DOSE/FREQUENCY
Date/time of
unless noted below, continue
Patient-friendly terms only
last dose
to take your medicines as
(Include concentration for liquids; all routes are by mouth unless listed otherwise)
prior to visit
prescribed prior to your
(“UNK” if
Patient not taking any home medicines
outpatient visit.
unknown)
Patient unclear about home medicines/doses/frequencies on entry
History Taken by:
Date:
Time:
also see addendum form
Review list with patient/responsible party.
Following MD update/signature, faxed to next care provider(s): Name(s):
by:
(Write “UNK” if unknown.)
Document Reviewed By MD/DDS
:
(MD signature not required if patient is admitted; admission/discharge form should be initiated)
Signature:
Date:
Time:
New Discharge Medicines (name, dose and frequency):
No new medicines
Discharge RN Signature:
Date:
Time:
Patient/Responsible Party Signature:
or
refer to ED Logicare documentation for signature
Carolinas HealthCare System
MEDICINE RECONCILIATION FORM
Outpatient Visit
page 1 of 2
version 5-5-08
Patient Identifier
*406*
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