Form 5-5- 08 - Medicine Reconciliation - 2007 Page 2
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2Patients :
1. Always keep this form with you. If you need help, ask a Nurse, Pharmacist, or a Doctor to help you fill out
this form.
2. This list of medicines is based on information you or a family member gave the hospital or doctor’s office and
any available records. If you have questions about your medicines, please ask your primary care provider
(doctor or nurse) or pharmacist.
3. Take this form to all Doctor visits and all medical testing (example: lab, x-ray, MRI, CT). Take this form to all
pre-assessment visits for admission, surgery, and hospital visits (ER, hospital admission, or out-patient visit).
4. Change this form as changes are made to your medicines. If a medicine is stopped, draw a line through it and
write the date the medicine is stopped. For example, if you are taking Digoxin and the doctor tells you to stop
taking it on August 16, this is how you mark the form. Digoxin 8/16/06
5. If you have a medical test, bring this form with you. A Doctor or Nurse will look at the form and make sure it
has the right information. They will give you the form back.
6. If you are in the hospital and are being discharged, you will receive a new form, which will have all of the
medicines you need to take. Someone will help you read the form and will give you a copy of it. When you get
the new form, throw away the old one. When you return to your doctor, take your new form with you. This
form keeps you, your family, and your healthcare providers up to date on your medicines.
7. Tell your family, friends, and neighbors about the benefits of using this form.
HOW DOES THIS FORM HELP YOU?
By using this form, it:
1. Reduces confusion and saves you time.
2. Improves communication. Provides your family/healthcare providers with a current list of all of your
medicines.
3. Improves Medicine Safety. Medicines that cannot be taken with other medicines are corrected. If you are
taking two medicines that are the same, the pharmacist, doctor, or nurse can correct it.
Carolinas HealthCare System
Page 2 of 2
Revised August 2007
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