Outpatient Medication Reconciliation Form - Radiology
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1Bon Secours Hampton Roads Radiology
Outpatient Medication Reconciliation Form
Maryview Medical Center
Harbour View Medical Center
DePaul Medical Center
Mary Immaculate Hospital
PATIENTS AND CARE GIVERS
: List (please print) all the patient's medications, including prescriptions, over the
counters, and herbal medications. If you need help with this list, please let us know and we can assist you. At discharge, you
will receive a copy of this form from the hospital staff.
Patient Name (Please Print): ___________________________________ Date: _____________________
Patient primary care provider: ______________________________________________________________________
Medication List
Name of medication
Dose & route
How often is it
Reason for Taking?
(include eye drops, vitamins,
taken?
herbals)
The above is based on the medication told to providers on this visit by the patient/ family. There may be instances where,
due to a patient/ family not recording a medication, a medication could be absent or unknown to the providers
Patient/Caregiver Signatures: __________________________________________ Relationship ___________________
Staff signature_______________________________________________________ Date/Time ____________________
At Outpatient Discharge:
The patient's current medications have been reviewed as written above by the patient or
caregiver(s). The following medication recommendations are made:
You’ve received IV Contrast for your test. A Change has been made to your regular home medication list; no prescription
[ ]
is needed. The change is listed below:
Name of medication to be
Hold for how long
Check with your doctor prior
held
to restarting (yes / no)
Staff Signature _____________________________________Date ____________Time_______
For Radiology Staff only
:
Faxed: Date: ____________ Time: ____________ Receiver: _________________ Initials: _______
MMC-3093-022
2/13, 3/14
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